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rslOTTE^S 


ON 


Frinciflbs  of  Surgbry, 


BY 


BLANTON  L.  HILLSMAN, 


CLASS   1898, 


UNIVERSITY  COLLEGE  OF  MEDICINE, 


FROM    LECTURES    BY 


Professor  of  Principles  of  Surgery,  University 
College  of  Medicine,  Richmond,  Va.;  Surgeon  to 
St.  LUKE'S  Home  and  Virginia  Hospital. 


Richmond,  Virginia: 

james  e.  goode  printing  company. 
1897. 


A 


PREFACE. 


The  following  "  ISTotes  ou  Principles  of  Surgery"  won  the  prize 
offered  by  Dr.  Stuart  McGuire  for  the  best  report  of  his  lectures 
for  the  session  '96-'97.  They  are  published  at  the  suggestion  of 
several  friends,  and  appear  almost  exactly  as  taken  in  the  classroom. 

I  realize  that  they  do  not  do  full  justice  to  my  teacher,  nor  re- 
flect great  credit  on  myself,  but  trust  that  they  may  prove  of  ser- 
vice to  my  fellow  students. 

BLANTOlSr  L.  HILLSMAK 

Richmond,  Ya., 

September  15,  1897. 


CONTENTS. 


The  Germ  Theory  op  Disease 

Surgical  Bacteriology .. 

"  "  Continued 
Inflammation , 

^'  Continued 


Process  op  Repair 

Regeneration  op  Special  Tissues. 


Continued. 


SUPPLTRATION. 


Continued  (Clinical  Forms). 


Ulceration 

Fistula 

Sinus 

Gangrene 

"        Continued  (Clinical  Forms) 

Shock — 

Septicemia 

Pyemia 

Erysipelas 

Tetanus 

Scurvy 

Wounds  in  General 

Special  Wounds 

"  "       Continued 


Influence  of  Constitutional  Conditions  Upon  Injuries 

Anthrax 

Hydrophobia 

Glanders 

Actinomycosis 

Tuberculosis 

Continued XXXIII 


LECTURE. 

page. 

I. 

1 

II. 

10 

III. 

14 

IV. 

19 

V. 

23 

VI. 

26 

VII. 

28 

VIII. 

33 

IX. 

37 

X. 

41 

XI. 

45 

XII. 

50 

XIII. 

54 

XIV. 

58 

XV. 

64 

XVI. 

70 

XVII. 

73 

XVIII. 

73 

XVIIl. 

73 

XVIII. 

76 

XIX. 

80 

XX. 

84 

XXI. 

88 

XXII. 

92 

XXIII. 

95 

XXIV. 

101 

XXIV. 

101 

XXV. 

107 

XXVI. 

112 

XXVII. 

119 

XXVIII. 

125 

XXIX. 

130 

XXX. 

136 

XXX. 

136 

XXXI. 

141 

XXXI. 

141 

XXXII. 

144 

XXXIII. 

149 

VI  CONTENTS. 

LECTURE.  PAGE. 

Clinical  Forms  op  Surgical  Tuberculosis XXXIV.  153 

Continued XXXV.  157 

"            "                   "                   "                   "        XXXVI.  161 

XXXVII.  166 

Rickets , XXXVIII.  170 

Hemophilia XXXVIII.  170 

Hysteria XXXVIII.  170 

Syphilis XXXIX.  175 

"        Continued.., XL.  181 

XLI.  185 

XLII.  190 

Tumors XLIII.  196 

"      (Benign) XLIV.  200 

"      (Malignant) XLV.  204 

Retention  Cysts XLVI.  208 

Aseptic  and  Antiseptic  Surgery XLVII.  212 


N  o  "r  e:  s 


ON 


Frinciplbs  of  Surgery. 


LKCTURE  I. 


THE    GERM   THEORY   OF   DISEASE. 

Ever  since  the  fall  of  man  from  his  perfect  state  he  has  been 
liable  to  disease,  and  being  a  selfish  as  Avell  as  an  intelligent  ani- 
mal, he  bas  demoted  much  study  to  its  cause,  in  order  that  ha 
might  avert  its  effects.  His  earliest  conceptions  of  disease,  while 
amusing,  -were  so  clouded  by  ignorance  and  superstition  that  they 
scarcely  deserve  mention.  The  great  Hippocrates,  the  father  of 
medicine,  for  instance,  maintaining  that  the  body  was  composed 
of  four  humors — blood,  phlegm,  black  bile  andj'-ellow  bile — a  right 
proportion  and  mixture  of  which  constituting  health,  an  improper 
proportion  or  irregualr  distribution  constituting  disease;  and  it 
was  not  until  the  Phlogistic  theory  was  advanced  that  we  have 
evidence  of  anything  like  scientific  reasoning.  The  Phlogistic 
Theokt  was  based  on  a  supposed  analogy  between  combustion 
and  disease.  Physicians  saw  pestilence  strike  a  community  like  a 
spark  strikes  among  straw  and  kindling,  attack  person  after  per- 
son in  society,  as  fire  would  leap  from  house  to  house  in  a  city. 
Stahl  had  taught,  and  his  views  were  generally  accepted  by  chem- 
ists, that  combustion  was  due  to  the  liberation  of  a  fluid  or  essence 
called  phlogiston^  which  was  inherent  in  all  matter,  and  it  was 
therefore  inferred  that  if  this  be  true  there  must  be  some  substance 
in  man  himself  which,  once  put  in  motion,  acted  similarly  to  fire 
and  spread  with  deadly  effect.     This  theory  was  long  held,  and 


2  PRINCIPLES    OF    SURGERY. 

evea  to  this  day  remedies  which  are  directed  against  inflauimation 
or  iniiammatory  conditions  are  called  anti-jphlogistics. 

The  next  hypothesis  of  importance  was  called  the  Zymotic  Theory, 
and  was  based  on  the  similarity  between  the  processes  of  fermen- 
tation and  disease.  It  was  known  that  vihen  yeast  was  added  to 
certain  solutions  containing  sugar  certain  changes  occurred.  It 
was  observed  that  a  very  small  quantity  of  yeast  \\  as  necessary 
to  inaugurate  these  changes;  that  the  quantity  cf  j^east  was  large- 
ly increased  by  the  changes,  and  that  the  new  3^east  thus  formed 
would  again  produce  fermentation  if  added  to  fresh  solutions.  It 
was  claimed  that  infectious  disease  presented  similar  characteris- 
tics; that  disease  was  started  by  the  introduction  into  the  body 
of  a  substance  similar  to  yeast;  that  the  quantity  of  the  substance 
was  increased  by  the  process,  and  that  the  substance  was  after- 
wards convej'^ed  from  the  sick  person  to  healthy  individuals,  thus 
repro'lucing  the  disease  and  rapidly  diffusing  it  through  a  com- 
munity. Confidence  in  the  '  '"zymotic  theory''''  of  disease  was  greatly 
strengthened  when  Jenner,  in  1798,  began  the  use  of  vaccine  virus 
as  a  preventive  of  small  pox.  Here  the  physician  had  a  substance 
which  he  could  carry  about  as  he  could  yeast.  He  could  intro- 
duce it  into  tne  skin  of  a  healthy  person,  and  after  a  certain  time 
a  disease  would  manifest  itself,  just  as  he  could  iotroduce  yeast  into 
a  solution  of  sugar,  and  after  a  certain  time  find  changes  of  fer- 
mentation. A  small  amount  of  either  was  sufficient,  and  in  each 
case  a  certain  period  of  rest  was  observed  before  the  characteristic 
changes  were  seen.  Nor  did  the  likeaess  stop  here.  It  was  found 
that  intense  heat  destroyed  the  power  of  yeast,  and  the  same  was 
found  to  be  true  of  vaccine  virus.  It  was  also  known  that  when 
a  solution  of  sugar  had  once  undergone  the  process  of  fermentation, 
further  change  would  rot  be  produced  by  adding  fresh  yeast  to  it, 
and  an  analogy  was  found  in  vaccination,  for  a  person  onr.e  vacci- 
nated is  rendered  insusceptible  to  further  inoculation  by  the  virus, 
at  least  for  some  years.  All  these  facts  furnished  the  strongest 
possible  proof  of  the  identity  of  the  two  processes,  at  least  in  mode 
of  operation,  however  wide  the  difference  in  results,  and  the 
theory  was  generally  accepted. 

With  the  advance  of  knowledge  during  the  present  century  the 
subjects  of  fermentation  and   putrefaction  were  earnestly  studied. 


PRINCIPLES    OF    SURGERY.  6 

Learned  men  in  all  parts  of  the  world  devoted  their  liv^es  to  their 
investigation;  but  it  remained  for  the  great  scientist  Pasteur  to 
announce  to  the  world,  in  1858,  their  real  nature.  It  had  pre- 
viously been  supposed  that  they  were  due  to  the  action  of  oxygen, 
and  were  a  purely  chemical  process.  Pasteur  proved,  by  a  series 
of  experiments,  whose  ingenuity  and  originality  have  rarely  been 
equalled,  that  they  were  due  to  the  action  of  a  living  micro- 
organism, and  hence  were  a  vital  process. 

There  lived  at  this  period  in  Glasgotv,  Scotland,  a  surgeon  named 
Joseph  Listf^r,  a  man  who,  despite  the  demands  of  an  active  prac- 
tice, found  time  for  theoretical  study.  He  read  \\ith  interest  the 
demonstrations  of  Pasteur  and  his  fellow-workers,  and  at  once  con- 
cluded that  the  discovery  was  of  great  practical  value.  12  fermen- 
tation and  putrefaction  could  be  prevented  by  exclusion  of  germs 
from  a  test  tube,  why  could  not  disease,  such  as  suppuration,  be 
prevented  by  exclusion  of  germs  from  a  wound?  On  this  premise, 
as  a  basis,  he  began  a  series  of  experiments,  and  soon  found  that  a 
wound  made  through  clean  skin,  by  a  clean  hand,  with  a  clean 
knife,  and  protected  by  a  clean  dressing  would  heal  without  in- 
fiamination  and  without  the  formation  of  pus.  The  results  were 
elaborated  and  published  jn  1865,  and  were  the  origin  of  "The 
Germ  Theory  of  Disease" — a  theory  ^ivhich  was  destined  to  revo- 
lutionize the  practice  of  medicine  and  surgery. 

The  application  of  the  principles  of  the  germ  theor}^  to  the  prac- 
tice of  medicine  and  surgery  has  been  of  untold  benefit  to  man- 
kind. In  surgery,  suffering  is  lessened,  convalescence  is  shortened, 
and  lives  of  patients  are  saved.  Regions  of  the  body  are  now 
safely  invaded  which  were  hitherto  believed  to  be  inaccessible,  and 
operations  are  now  successfully  performed  which,  if  suggested  be- 
fore, would  have  been  considered  the  outcome  of  a  diseased  brain, 
or  the  freak  of  a  disordered  imagination.  It  is  difficult  for  you 
who  visit  the  hospitals  of  to-day  and  see  the  comfortable  patients 
in  their  clean  and  airy  v^ards,  their  wounds  covered  with  artistic 
dressings  and  their  faces  free  from  evidences  of  pain  or  fever,  to 
realize  the  dangers  which  beset  a  patient  before  the  antiseptic  era, 
or  to  have  any  conception  of  the  horrors  of  a  metropolitan  hospital 
of  the  olden  time.  I  recently  read  a  description  by  a  French  writer 
of  the  Hotel  Dieu,  of  Paris,  a  hospital  whose  wards  were  immedi- 


4  PRINCIPLES    OF    SURGERY. 

ately  over  the  dead  house,  and  whose  atmosphere  reeked  with  the 
odors  of  putrefaction.  A  hospital  whose  only  heat  emanated  from 
the  bodies  of  its  tv  retched  inmates,  and  whose  only  ventilation  was 
derived  from  the  accidental  defects  of  its  structure.  A  hospital 
whose  walls  "weie  soiled  by  expectorations  from  patients,  and  whose 
floors  were  covered  with  blood  and  pus  from  wounds.  Into  this 
pest  house  patients  were  packed  four  and  sii^  in  a  bed,  and,  in 
emergencies,  were  placed  in  tiers  one  over  the  other,  so  that  some 
were  reached  only  by  the  use  of  ladders.  It  is  not  surprising  that 
gangrene  and  erysipelas  were  rife,  and  that  one  out  of  every  four 
patients  died.  Lister  is  the  magician  who  has  wrought  the  change; 
the  germ  theory  the  agent  he  employed. 

Id  medicine,  too,  the  results  accomplished  have  been  marvelous. 
Plagues  are  prevented,  epidemics  are  arrested,  and  contagious 
diseases  are  cured.  One  of  the  drst  great  discoveries  in  this  de- 
partment was  Pasteur's  treatment  of  hydrophobia  by  inoculation. 
This  great  scientist,  in  order  to  study  the  disease,  produced  it  arti- 
ficially in  a  rabbit  by  injecting  under  its  skin  some  virus  taken 
from  the  mouth  of  a  rabid  dog.  When  the  rabbit  finally  died,  he 
took  some  of  its  blood  and  injected  it  into  a  fresh  animal,  and 
hydrophobia  again  developed.  He  noticed  that  the  second  case 
was  more  severe  than  the  first,  and  further  experiments  proved 
that  the  disease  became  ncore  intense  each  time  it  was  reproduced. 
Pasteur  concluded  that  if  the  germ  became  more  virulent  under  cer- 
tain circumstances,  that  there  must  be  other  conditions  which 
would  render  it  milder.  Investigation  at  length  resulted  in  the 
discovery  of  these  conditions,  and.  in  the  production  of  germs  which 
were  so  attenuated  that  they  could  not  produce  the  aisease  in  an 
animal,  but  would  protect  it  from  an  attack  of  the  disease.  A 
patient  who  has  been  bitten  by  a  rabid  animal  can  now  be  pro- 
tected from  the  disease  b}'"  being  inoculated  with  weakened  germs, 
and  hydrophobia,  formerly  the  most  horrible  and  hopeless  of  ali 
diseases,  has  been  robbed  of  its  terrors. 

The  civilized  world  was  startled  not  many  years  ago  by  the  an- 
nouncement that  Koch,  of  Berlin,  had  discovered  a  remedy  for 
tubsrculosis,  the  dread  disease  which  causes  the  death  of  one  out 
of  every  seven  people  who  die.  It  was  a  well  known  fact  that  no 
animal  could  live  in  its  own  excreta;  and  by  injecting  the  products 


PRINCIPLES    OF    SURGERY.  5 

of  the  bacillus  tuberculosis  into  the  body  of  a  patient  suffering  from 
consuiT.  ption,  it  was  belie'^ecl  the  disease  could  be  cured.  The 
treatrcent  was  published  preraaturely,  published  before  its  value 
was  determined  by  experiments,  published  without  the  consent  of 
its  originator.  Koch's  lymph  or  tuberculin  has  proven  of  little 
■value,  but  it  was  an  advance.  Other  investigators  are  now  work- 
ing on  the  same  lines,  and  we  may  look  forward  to  the  result  of 
the  future  with  hope  and  with  confidence. 

Cancer,  the  terror  of  its  victim,  the-  "J^fe  noir''^  of  the  surgeon, 
is  by  some  believed  to  be  due  to  a  germ.  It  has  been  observed 
that  its  advance  is  frequently  checked,  and  in  eome  instances  the 
disease  is  absolutely  cured,  by  accidental  attacks  of  erysipelas.  In- 
vestigation has  shown  that  there  is  an  antagonism  between  the 
microbe,  which  is  know^n  to  cause  erysipelas,  and  on  the  principle 
of  fighting  fire  with  fire,  erysipelas  is  used  to  fight  cancer.  The 
cancerous  growth  is  inoculated  with  erysipelas,  and  sometimes  the 
cancer  is  conquered.  It  is  a  desperate  remedy,  but  it  is  used  in 
desperate  cases.  Statistics  certainly  justify  further  investigation 
of  the  subject.     The  future  only  can  determine  its  value. 

The  last  advance  which  the  germ  theory  has  accomplished  is  iu 
the  treatment  of  diph^-heria,  a  disease  which  hurries  to  an  untimely 
grave  so  many  of  its  victims.  The  treatment  is  an  endeavor  to  in- 
crease the  antiseptic  po\;^  er  of  the  blood,  and  thus  destroy  the  germ 
which  produces  the  disease,  and  is  carried  out  by  injecting  beneath 
the  skin  of  a  patient  suffering  v/ith  diphtheria  a  substance  called 
Antitoxin.  Antitoxin  is  prepared  in  the  following  way:  The 
germ  of  diphtheria  is  placed  in  a  test  tube  containing  iDroth,  and 
allowed  to  grow  for  ten  or  twelve  days.  At  the  end  of  that  time 
it  has  saturated  the  broth  with  its  specific  poison,  or  jptomaine. 
The  contents  of  the  tube  is  then  boiled,  the  heat  killing  the  germ, 
but  having  no  effect  on  the  chemical  poison  it  has  produced.  A 
young  and  healthy  horse  is  taken,  and  a  few  drops  of  the  solution 
injected  beneath  the  skin.  It  makes  him  very  sick;  he  has  high 
fever,  loses  flesh  and  refuses  to  eat,  but  usually  he  recovers  in  two 
or  three  days,  and  at  the  end  of  a  week  is  apparently  well.  He  is 
then  injected  with  the  same  material — -this  time  twice  the  former 
dose  being  used — and  again  the  same  symptoms  come  on,  though 
not  so  well  marked.     This  weekly  dose  of  poison  is  continued  for 


6  ,  PKINCIPLES    OF    SURGERY, 

about  six  months,  when  the  horse  is  found  to  have  acquired  a  toler- 
ance to  its  action,  and  can  take  an  enormous  dose  without  any  bad 
effects  being  observed.  To  use  a  technical  term,  the  horse  has 
become  immune.  As  soon  as  this  is  accomplished,  the  horse's 
neck  is  shaved  and  disenfected,  one  of  the  jugular  veins  opened, 
and  about  two  gallons  of  blood  withdrawn.  The  blood  is  allowed 
to  cool,  and  the  serum  separated  from  the  other  constituents.  The 
serum  conlains  the  antitoxin,  and  is  concentrated  and  put  in  a  suit- 
able form  for  use.  Before  it  is  placed  on  the  market,  its  power  and 
strength  is  tested  by  observing  its  effects  on  G-uinea  pigs,  in  whom 
diphtheria  has  been  artificially  produced.  The  action  of  this  new 
agent  on  diphtheria  is  remarkable.  Used  in  the  early  stage,  it  alwaj^'s 
cures,  and  it  is  only  when  its  employment  is  too  long  delayed  that  it 
fails.  I  have  mentioned  only  a  few  of  the  many  important  results 
which  the  germ  theory  has  accomplished.  Only  enough  to  show 
yo'j  Its  present  practical  value.  Earnest  men  in  all  parts  of  the 
civilized  world  are  working  night  and  day  upon  the  subject  and  no 
one  can  predict  what  the  ultimate  outcome  will  be.  Perhaps  the 
possibilities  are  not  exaggerated  by  a  French  writer,  who  says: 
"When  man  learned  to  protect  himself  from  wild  beast,  he  made 
the  first  step  in  civilization.  To-day  man  is  learning  how  to  defend 
himself  from  microbes;  it  is  a  step  of  equal  importance.  A  day  will 
come  when  in  Berlin,  in  London,  in  Paris,  a  man  will  not  die  of 
diphtheria,  of  typhoid  fever,  of  scarlet  fever,  of  cholera,  or  of 
tuberculosis,  any  more  than  he  dies  in  these  cities  to-day  of  the  venom 
of  snakes  or  the  teeth  of  wolves,''  Candor  compels  me  to  admit 
that,  despite  the  facts  which  I  have  adduced,  and  the  logical  con-, 
elusions  which  they  bring,  that  the  germ  theory  has  not  yet  been  uni- 
versally accepted,  and  that  there  are  still  some  men  of  prominence 
who  do  not  yield  in  practice  to  its  teaching.  The  medical  skeptics 
are  much  more  numerous  than  the  surgical  infidels,  and  this  is  ex- 
plained bv  the  fact  that  medicine  is  yet  but  an  art,  while  surgery 
is  a  science.  The  physician  treats  maladies  which  are  hidden  from 
his  sense  of  touch  and  sight,  and  whose  symptoms  give  but  vague 
indications  of  their  real  nature.  He  goes  to  the  bedside  of  a  pa- 
tient,  feels  the  pulse,  examines  the  tongue,  auscultates  and  percusses 
the  chest,  and  prescribes  medicines  uncertain  iii  their  indication 
and  indefinite  in  their  action,  and  then  either  turns  a  prayerful  eye 


PRINCIPLES    OP    SURGERY.  7 

heavenward,  or  calls  long  and  loudly  on  mother  nature  for  assist- 
ance. It  is  natural  that  he  should  regard  the  germ  theory  w;ith 
suspicion.  The  surgeon,  on  the  other  hand,  meets  the  enemy  face 
to  face,  and  in  his  bloody  battle  with  disease  for  the  life  or  death 
of  a  patient,  appreciates  his  power,  and  recognizes  the  potency  of 
his  remedies.     By  him  the  germ  theory  is  accepted. 

Only  one  surgeon  of  great  prominence  lives  who  denies  its  va- 
lidity, and  this  is  "Mr.  Lawson  Tait,  of  England,"  a  man  v^  hose 
wonderful  success  in  abdominal  work  has  made  his  name  famous 
throughout  ihe  civilized  world,  but  whose  love  of  notoriety  renders 
the  honesty  of  his  views  open  to  suspicion.  In  a  recent  paper  read 
before  the  Birmingham  and  Midland  Branch  of  the  British  Medi- 
cal Association,  entitled,  "A  Criticism  of  the  Germ  Theory  of 
Disease  Based  on  the  Baconian  Method,"  he  represents  the  views 
of  the  agnostics  as  strongly  and  vigorously  as  it  is  possible  for 
them  to  be  put.  At  the  onset  of  bis  remarks,  he  says  he  wants  to 
remind  those  persons  who  now  sneer  at  his  views  as  those  of  a 
mere  practioner,  that  for  twelve  years  he  was  a  hard  working  and 
enthusiastic  raicroscopist,  and  that  during  that  time  he  discovered 
much  which  was  then  unknown  and  unraveled  the  minute  anatomy 
of  certain  structures  with  a  completeness  chat  has  defied  further 
addition.  He  says  that  the  germ  theory  is  simply  an  amusing  hy- 
pothesis, by  which  everything  is  explained  and  under  which  every- 
thing is  squeezed.  He  says  that  the  fact  that  the  origin  of  certain 
diseases  is  due  to  a  poison  has  alwavs  been  recogrnized,  but  the  sus;- 
gestion  of  the  immediate  machinery  has  curiously  varied.  The 
ancient  Greeks  and  Hebrews  believed  that  disease  was  a -blow  from 
an  offended  deity,  and  the  Christian's  favorite  doctrine  was  that 
it  was  a  visitation  from  the  devil;  for  both  the  modern  scientist 
has  substituted  the  microbe,  which  is  no  logical  advance  over  the 
belief  of  either.  The  ancient  Jews  were  very  practical  and  busi- 
ness like  people,  and  could  have  written  sanitary  articles  in  medi- 
cal journals  much  better  than  some  of  their  descendants  do  now. 
They  knew  the  facts  of  sepsis,  and  had  the  most  elaborate  schemes 
of  antisepsis,  whose  stringency  of  detail  were  not  much  more  ridic- 
ulous, or  probably  much  less  satisfactory,  than  many  of  those  which 
have  emanated  from  Lister  himself.  Mr.  Taic  then  takes  up  the 
application  of  the  germ  theory  to  the  practice  of  surgery,  and  says 


PRINCIPLES    OF    SURGERY, 


that,  being  a  very  clumsy  barber,  hp  has  no  doubt  he  h?s  implanted 
myriads  of  germs  in  fresh  v^ounds  inflicted  on  his  face  while  shav- 
ing, and  that  no  septic  results  have  followed  in  his  own  case  or  in 
thousands  of  fellow  sufferers.  He  ridicules  the  technique  of  anti- 
septic surgery,  and  uses  as  an  illustration  of  its  absurdity  an  article 
recently  written  bv  an  American,  in  which,  with  great  enthusiasm, 
the  writer  describes  the  method  by  which  he  performs  an  exceed- 
ingl}^  simple  operation  en  a  child,  giving  in  detail  the  antiseptic 
precautions.  He  observes:  "Sterilized  gauze,  sterilized  bandages, 
and  a  properly  sterilized  cradle  and  nurse,"  saysMr.  Tait,  "secures 
the  recovery  of  the  germ -endangered  baby,  and  no  doubt  a  formal 
operation  fee  is  charged  after  the  danger  is  all  over."  Mr.  Tait 
sa3''s  that  he  has  done  a  good  deal  of  operative  work,  and  he  has 
never  used  anything  but  absolute  cleanliness,  and  yet  his  published 
statistics  have  never  been  equalled.  He  says  he  has  challenged  Sir 
Joseph  Lister  over  and  over  again  to  compare  results  with  him, 
but  he  has  ignored  him  with  lordly  indifference.  He  says  that  the 
details  of  Listerism  change  with  marvellous  rapidity,  and  before 
they  are  six  months  old,  are  pronounced  failures  and  are  replaced 
by  something  new.  The  lastof  all  these  numerous  phases  isthedis- 
use  of  chemical  destroyers  of  genus  and  the  adoption  of  aseptic  sur- 
gery, which  is  nothing  but  perfect  cleanliness,  a  principle  which 
he  has  been  preaching  for  years,  and  now,  forsooth,  it  is  the  new- 
est Listerism.  Mr.  Tait  says  that  after  his  early  experience  in  sur- 
gery, it  is  a  wonder  he  ever  stuck  to  it;  that  duriog  his  pupilage  in 
Edinburgh,  he  saw  thirty  abdominal  tumors  removed  without  a 
single  recovery,  and  that  when  he  left  the  land  of  his  birth  it  was 
with  one  fully  made  resolution — that  he  would  never  open  an  ab- 
domen. In  Edinburgh,  if  he  saw  the  amputation  of  a  thigh  Id  the 
old  Infirmary  on  Wednesday,  there  was  a  strong  probability  that 
the  following  week  he  would  see  the  bared  bone  sticking  through 
the  anterior  flap.  If  a  breast  was  removed,  an  erysipelatory  red- 
dening of  the  flap  would  very  probably  ccGur  on  the  foUov^ing  day, 
and  would  he  half  w^ay  round  the  chest  before  the  week  was  out, 
and  the  wound  gaping  and  every thmg  going  to  the  bad.  lie  left 
Edinburgh,  and  has  been  engaged  continuously  for  the  past  twenty- 
eight  years  in  making  wounds,  and  he  has  never  seen  a  case  of  ery- 
sipelas in  his  own  practice.     The  improvement  lies  in  the  separa- 


PRINCIPLES    OF    SURGERY.  9 

tion  of  patients,  plenty  of  cubic  space  and  fresh  air  and  is  in  nowise 
the  result  of  chemical  germicides,  Mr.  Tait  says  that  it  was  Simp- 
son who  cried  out  most  loudly  for  better  ventilation  and  cleanli- 
ness, and  against  the  use  of  dirty  hands  and  sponges,  and  he  has 
been  dead  hardly  these  five  and  twenty  yee;rs,  and  all  his  splendid 
work  is  as  much  forgotten  as  if  it  had  never  been  done,  and  the 
glorious  progress  which  has  come  out  of  it  is  given  to  a  theory, 
which  is  no  theory  at  all,  but  a  phantasm,  a  system  which  has 
been  proven  an  inconstancy  and  a  broken  leed — a  thing  vvhich 
yields  at  every  blast,  either  to  scholastic  logic  or  eclectic  experience. 
It  will  be  seen  that  Mr.  Tait  recognizes  the  existence  of  a  poison 
which  produces  disease,  but  refuses  to  admit  that  it  is  of  microbic 
nature.  He  insists  upon  the  importance  of  cleanliness,  and  upon 
the  avoidance  of  contaminating  wounds  with  dirt,  but  fails  to  say 
of  what  dirt  consists.  He  prefers  to  deal  in  generalities — to  speak 
of  contagion  as  a  condition,  not  an  entity.  If  it  gratifies  him  to 
call  by  the  name  of  dirt  what  his  more  advanced  contemporaries 
have  resolved  into  micro-organisms^  it  is  a  weakness  of  his  brain, 
which  should  be  pardoned  on  account  of  the  cleverness  of  his 
hands.  If,  in  practicing  cleanliness,  Mr.  Tait  has  practiced  aseptic 
surgery,  so  much  the  better  for  Mf.  Tait;  but  he  did  it  instinc- 
tively, purposely,  and  to  have  expected  others  to  follow  an  example, 
for  which  he  could  give  no  reason,  would  be  as  illogical  as  to  ex- 
pect fruit  from  a  tree  which  had  no  roots  or  water  in  a  brook  which 
had  no  source. 

The  followers  of  Lister  have,  in  the  past,  been  guilty  of  many 
absurdities,  and  in  their  ranks  are  still  found  theorists  ^vho  ride 
their  hobbies  hard.  Many  apparently  contradictory  facts  still  re- 
main unexplained,  and  the  results  of  experiments,  which  seem  dia- 
metrically opposed,  huve  still  not  been  reconciled,  but  all  this  will 
be  remedied  in  time.  When  germs  can  be  examined  micrcscopi- 
cally,  can  be  differentiated  by  appearance,  can  be  cultivated  in  the 
laboratory,  and  can  have  their  effect,  when  introduced  into  a 
healthy  organism,  accurately  foretold,  the  science  of  bacteriology 
is  not  a  farce.  When  a  germ  fulfills  the  requirements  of  Koch's; 
when  it  is  always  found  accompanying  a  disease;  when  it  can  be 
cultivated  from  the  tissues  of  the  animal  dead  of  the  disease,  and 
when  it  will  reproduce  the  disease  if  inoculated  into  a  second  ani- 


10  PRINCIPLES    OF    SURGERY. 

mal,  it  certainly  seems,  to  aa   unprejudiced  mind,  that  it  is  the 
cause  of  the  disease. 

It  is,  cf  course,  impossible  to  demonstrate  positively  the  truth  of 
the  '"'"Germ  Theory^''''  but  such  is  the  case  in  many  other  branches 
of  science,  and  is  no  reflection  upon  medicine.  No  one  would  ques- 
tion for  a  moment  the  assumption  of  tbe  truth  of  the  ^"•atoiyiic 
theory,''''  and  yet  without  that  basis  upon  which  to  build,  the  proud 
structure  which  has  been  erected  by  the  chemist  would  fall  into 
chaos.  It  is  impossible  for  the  Christian  to  demonstrate  the  exist- 
ence of  a  '''Deity,''^  and  yet,  without  the  faith  inspired  by  their 
belief,  civilization  would  totter  and  barbarism  return. 


LECTURE  II. 


SURGICAL   BACTERIOLOGY. 

Bacteria,  Micro-organisms,  Microbes  or  Germs,  are  synonymous 
terms  for  minute  vegetable  plants  belonging  to  the  lowest  order  of 
the  vegetable  kingdom  and  are  closely  allied  to  tbe  algae.  As  the 
rr»inute  cells  possess  the  power  of  motion,  they  were  for  a  long 
time  thought  to  be  of  the  animal  kingdom,  but  this  theory  has  been 
abandoned.  There  are  two  kinds  ot  bacteria — JSfon-pathogeniG^  or 
those  which  do  not  cause  disease,  and  Pathogenic,  or  those  which 
cause  disease. 

NoN-PATHOGENic  germs  produce  fermentation  and  putrefaction. 
They  are  seen  producing  fermentation  in  the  manufacture  of  beer 
as  yeast  and  in  removing  dead  bodies  by  putrefaction. 

Pathogenic  germs  produce  disease  and  are  of  many  kinds,  exceed- 
ing minute  in  size,  being  from  1  to  4:  MM.  in  diameter.  One 
writer  speaks  of  them  as  the  ''infinite  little,'''  another  says  they 
require  to  be  magnified  seven  hundred  times  to  be  seen,  and  still 
another  claims  that  one  thousand  of  them  can  pass  through  the  eye 
of  a  needle  abreast.  They  are  composed  of  protoplasm,  are 
unicellular,  the  nuchus  and  nucleolus  has  not  been  found,  but  prob- 


PRINCIPLES    OF    SURGERY.  11 

ably  e.^ist.  The  protoplasm  consist  of  an  albuminous  substance 
called  Mycoprotein^  and  is  incased  in  a  membrane  of  cellulose  con- 
taining a  little  fat.  So  we  may  define  a  bacteria  by  saying:  1.  It 
is  a  plant;  2.  It  is  a  cell;  3.  It  is  formed  of  protoplasm;  4.  It  is 
incased  in  a  membrane. 

Most  all  bacteria  are  colorless  and  transparent,  but  occasion- 
ally some  are  found  that  are  colored,  such  as  bine,  red,  etc.  A 
great  many  are  capable  of  motion  which  is  accomplished  by  the 
movement  of  their  processes  called  Cilia;  others  are  not  capable  of 
motion  and  are  carried  by  the  fluids  cf  the  bodj^.  In  looking  at  a 
microscopic  preparation  you  will  see  single  bacteria  and  also  will 
find  them  in  masses,  these  masses  are  formed  by  their  investing 
membrane  becoming  glutmous  and  they  adhere  one  to  another  and 
are  called  Zooglea. 

Thp^oky  of  a  Common  Botanical  Origin  of  Microbes. — All  bac- 
teria at  one  time  were  supposed  to  have  a  common  origin;  it  was 
thought  the  children  of  any  parent  might  be  a  cocci  ov  spurilli^  and 
any  one  of  them  might  produce  Tetanus  or  Erysipelas  or  any  of 
the  specific  diseases.  ■  This  theory  has  been  discarded,  and  it  is 
now  known  that  the  round  o^erm  beo^ets  a  round  o;erm,  the  o:erm  of 
suppuration  begets  a  germ  of  suppuration,  the  germ  of  erysipelas 
begets  a  germ  of  erysipelas,  there  being  no  possibility  of  crossing 
them,  as  they  invariably  breed  true. 

Three  Principal  Forms  of  Bacteria. — We  recognize  three  forms 
of  bacteria:  1..  The  round  or  coccus^  2.  The  rod  or  Bacillus;  3. 
The  curved  or  Spirillum,  The  cocci  are  comparatively  easy  to 
kill,  and  fortunately  for  the  surgeon  they  are  the  cause  of  most 
of  the  diseases. 

Combination  of  Cocci. — If  a  coccus  meets  another  and  they  join 
it  is  called  a  DiploGocci\  when  four  of  them  join  it  is  called  a  Mic- 
rococci tetragones;  when  they  form  a  chain  it  is  called  a  Strepto- 
cocci; when  they  form  like  a  bunch  of  grapes  it  is  called  a  Staphy- 
lococci. 

Multiplication  of  Bacteria. — Bacteria  are  capable  of  multipli- 
cation or  reproduction  which  takes  place  by  two  processes — Fis- 
sion and  Spore  formation. 

Reproduction  by  fission,  when  observed  under  the  microscope, 
the  baceria  at  first  is  seen  to  get  longer  and  a  little  oval  in  shape, 


12  PRINCIPLES    OF    SURGERY. 

a  depressioQ  is  next  seen  in  tbie  bacteria,  "which,  causes  it  to  assume 
a  dumbbell  shape,  the  depression  increases  and  finally  the  bacteria 
splits  into  two  equal  halves,  the  halves  grow  and  soon  become  as 
large  as  the  mother  cell  and  is  then  capable  cf  propagation  and 
reproduction. 

Reproduction  by  spore  formation :  Take  a  bacillus  under  the 
microscope,  it  looks  homogeneous  and  transparent  at  first,  then 
near  the  centre  you  will  see  a  slight  thickening  ^vhich  gradually 
increases  in  size,  becomes  moie  round  and  approaches  the  margin 
ot  the  cell,  it  finally  reaches  the  margin  of  the  investing  memcrane, 
produces  pressure  on  it,  causing  it  to  disintegrate  and  the  spore 
burst  thr-^ugh  and  is  set  free;  its  subsequent  feats  depends  on  the 
soil  it  gets  into.  The  cocoi  always  divides  by  fission,  the  hacilli 
by  spoie  formation  and  the  sjnrilli  may  divide  either  by  spore 
formation  or  fission. 

Ohaf.acteeistics  of  Spores. — Spores  differ  from  bacteria  in  their 
resisting  power  to  external  influences.  It  is  invested  by  a  thick, 
tough  shell,  which  makes  it  harder  to  kill  and  to  render  immune. 
So  when  dealing  \\ith  a  cocci  you  can  make  your  material  more 
sterile,  because  they  are  easy  to  kill,  but  when  dealing  with  a 
bacilli,  which  is  always  accompanied  by  spores,  it  is  harder  to  kill, 
and  therefore  you  will  have  to  use  stronger  gerixicides  than  when 
dealing  with  a  cocci,  but,  as  before  said,  we  are  fortunate  that  the 
cocci  cause  most  of  the  diseases. 

Essential  Conditions  foe  the  Growth  of  Germs, — Bacteria  are 
plants  and  require  certain  conditions  for  their  growth  and  repro- 
duction. The  most  important  conditions  are  Temperature,  Food 
and  Moisture.  The  temperature  varies  for  different  germs,  some 
require  low  and  some  high  temperatures,  but  most  of  them  grow 
better  between  86  degrees  and  104  degress  F.  Some  grow  below 
86  degrees  F.,  others  above  104  degrees  F.  Most  of  them  find 
the  temperature  of  the  body  most  delightful.  The  food  must  be 
of  organic  matter,  the  best  is  decomposing  organise  matter.  They 
require  moisture  as  well  as  any  other  plant.  A  certain  degree  of 
heat  is  necessary  for  the  life  of  a  germ,  but  if  it  is  carried  too  high 
it  is  death  to  them;  some  are  killed  at  140  degrees  F.,  others  at 
180  degrees  F.,  their  hardihood  varies  with  the  species,  but  all 
perish  when  kept  at  212  degrees  F.  for  any  length  of  time.     Moist 


PRINCIPLES    OF    SURGERY.  13 

heat  is  much  more  eihcacious  than  dry  heat.  Moist  heat  will  kill 
any  germ  at  212  degrees  F.  in  five  minutes.  It  is  the  popular 
opinion  that  cold  kills  bacteria;  this  is  not  so,  it  makes  them  inca- 
pable of  infection  for  awhile,  but  after  being  thawed  out  they  infect 
with  as  much  virulency  as  ever.  Cohn  subjected  germs  to  a  tem- 
perature of  180  degrees  below  zero,  and  then  gradually  brought 
them  back  to  their  original  temperature,  and  when  injected  into  an 
animal  they  produced  their  specific  disease.  Acids  are  death  to 
germs,  whereas  they  thrive  in  an  alkaline  media.  The  germicidal 
drugs  are  Bichloride  Mercur^^  1-10,000  will  kill  them  and  1-1,000 
will  render  anything  sterile.  This  drug  should  be  used  with  cau- 
tion, as  it  is  a  powerful  poison.  Carbolic  Acid  ranks  second,  a 
solution  of  1-100  will  exterminate  germs  and  a  3  per  cent,  solution 
will  sterilize  instruments.  While  carbolic  acid  in  water  is  a  power 
ful  germicide,  in  oils  it  is  inert.  Boracic  and  Salicylic  acids  are 
used  in  a  2  per  cent,  solution  for  irrigating  wounds.  Iodoform  is 
a  powder  applied  to  wounds  to  prevent  fermentation  and  putrefac- 
tion. It  is  not  an  antiseptic  in  the  dry  state,  as  germs  will  grow 
in  it,  but  when  it  comes  in  contact  with  the  secretions  it  gives  off 
free  iodine,  which  is  an  antiseptic. 

DisTEiBUTioN  OF  Baoteeia  IN  Natuke. — Bactcria  are  found  every 
where,  en  the  skin,  clothes,  in  the  air,  water,  mouth,  etc.,  and  it 
is  only  by  the  provisions  of  nature  that  we  are  protected. 

Divisions  of  Pathogenic  Bacteria: 

1.  Saprophyte — Lives  in  dead  matter  only. 

2.  Parasite — Lives  in  living  matter  only. 

3.  Ectogenous — Lives  only  outside  of  the  body. 

I.  Endogenous — Lives  only  inside  of  the  body. 

5.  Aerobic— Eequires  oxygen  for  life. 

6.  Anaerobic — Does  not  require  oxygen  for  life. 

7.  Chromogenous —Imparts  color  to  fluids  in  which  it  grows. 
S.  ISTon-chromogenous — Does  not  impart  color  to  fluids. 

9.  Pyogenic — Produces  pus. 

10.  Non-pyogenic — Does  not  produce  pus. 

II.  Gasogenic — Grrowth  results  in  the  formation  of  gas. 
12,   Non  gasogenic — Does  not  produce  gas  on  growth. 


14  PRINCIPLES    OF    SURGERY. 


JLECTURK  III, 


SURGICAL  BACTERIOLOGY— Continued. 

Toxins  and  Ptomaines. — When  a  pathogenic  germ  is  put  in  a 
test  tube  or  introduced  into  the  tissues  of  the  body  under  suitable  1 
conditions,  it  generates  a  poison  which  is  known  as  ^''Toxins  or 
Ptomaines.''''  It  is  not  definitely  known  how  this  material  is 
elaborated,  and  many  different  theories  exist  to  explain  its  produc- 
tion. The  simplest  and  most  plausible  is  that  gern  s,  like  all  other 
organisms,  have  excretions,  and  that  the  excrementitious  matter 
which  they  throw  off  constitutes  the  poison.  Toxins  and  Pto- 
maines are  chemical  substances,  and  are  not  affected,  as  are  bacteria, 
by  either  heat  or  germicides.  They  closely  resemble  the  vegetable 
alkaloids — strychnine,  morphine  and  atropine;  and  when  intro- 
duced into  the  system  cause  serious  disturbances.  There  is  a  char- 
acteristic difference  between  bacteria  and  its  ptomaines  or  toxins;  ' 
bacteria  is  a  living  cell,  capable  of  reproduction;  toxins  or  pto- 
maines do  not  possess  this  function  of  reproduction  and  produces 
their  effects  just  as  any  other  alkaloid,  and  the  symptoms  are  in 
proportion  to  the  amount  and  variety  injected.  The  ptomaine  or 
toxin  of  different  germs  has  distinct  characteristics.  Thus  the 
ptomaine  of  the  germ  of  suppuration  produces  pus,  the  ptomaine 
of  the  germ  of  lockjaw  produces  convulsions,  and  the  ptomaine  of 
the  germ  of  diphtheria  produces  paralysis. 

Entrance  of  Bacteria  Into  the  Body. — Bacteria  comes  from 
without,  and  are  conveyed  to  the  body  by  actual  contact.  The 
air  rarely  convey  germs  to  a  wound,  but  they  are  in  planted  by 
dirty  hands  and  instruments  coming  in  contact  with  the  '^ound. 
Lister  would  not  operate,  not  many  years  ago,  unless  the  air  of  the 
room  was  made  sterile,  he  had  an  assistant  on  either  side  of  the 
operating  table  with  sprays  of  antiseptic  solutions  playing  around 
the  wound  to  sterilize  the  atmosphere;  this  source  of  infection  has 
been  proven  to  be  of  minor  importance,  and  instead  we  make  our 
hands  sterile,  our  instruments  sterile,  and,  in  fact,  everything  that 


PRINCIPLES    OF    SURGERY.  15 

is  in.  danger  of  coining  in  contact  with  the  wound.  So  we  make 
these  conclusions:  That  there  are  but  few  bacteria  in  the  atmos- 
phere; that  bacteria  are  not  conveyed  to  wounds  by  the  air,  but  b}?" 
actual  contact  of  dirty  hands  and  instruments. 

Bacteria  cannot  pass  through  the  unbroken  skin  or  mucous  mem- 
brane, they  act  as  an  effectual  barrier,  and  only  when  there  is  some 
lesion  or  '■'■Infection  Atrium^'  can  they  enter.  After  the  germs 
ha\e  entered  the  body  through  the  broken  skin  or  mucous  mem- 
brane other  conditions  are  necessary  before  they  can  cause  disease, 
they  may  circulate  freely  in  the  blood,  but  will  cause  no  diseased 
conditions.  So  we  say  and  prove  that  it  is  to  their  localization, 
which  takes  place  if  they  find  an  impaired  or  weakened  tissue  or 
'•'■LoGxis  Minoris  ResistenlicB.''''  Experiments  prove  the  above:  A 
solution  of  the  germs  of  putrefaction  was  made  and  injected 
directly  into  the  blood  of  a  healthy  lamb,  but  no  disease  resulted; 
another  lamb  was  taken,  his  testicles  crushed  and  the  germs  in- 
jected and  Gangrene  resulted;  in  the  last  experiment  the  germs 
found  a  weak,  injured  testicle  in  which  the}'^  could  localize. 

Action  of  I^athogenic  Bacteria  on  the  Tissues  of  the  Body. — 
It  is  not  fully  settled  how  bacteria  acts  on  the  living  tissues;  some 
produce  locally  irritation  or  Inflamation;  and  the  chemical  sub- 
stances produced  in  this  process  is  absorbed  and  diffused  through- 
out the  body,  and  in  virtue  of  its  ferment-like  action  greatly  in- 
creases the  tissue  metamorphosis  and  acting  on  the  thermic  centres 
produces  fever  and  other  constitutional  disturbances  known  as  Sep- 
tic  Intoxication  cr  Toxic  Infection. 

Elimination  of  Pathogenic  Bacteria. — 'After  the  germs  have 
entered  the  body  and  finds  no  suitable  soil  to  live  in,  how  does  na- 
ture dispose  of  them?  It  is  accomplished  by  Phagocytosis  and  Ex- 
cretion. The  blood  is  not  only  itself  a  powerful  antiseptic,  but  it 
contains  a  cell  called  Phagocyte  or  white  blood  corpuscle,  whose 
duty  it  is  to  protect  its  home  and  to  attacK  all  invaders.  The 
phagocyte  is  capable  of  swallowing  a  bacteria,  digesting  and  excre- 
ting them  inca])able  of  producing  disease.  When  the  phagocyte 
and  the  germ  meets  a  battle  royal  ensues,  aad  the  phagocyte  is 
usually  the  victor,  unless  the  germs  are  in  such  numbers  to  success- 
fully overpower  them,  when  the  reserve  guard,  the  emunctory 
organs,  are  ordered  to   the  front.     It  can  b*^  proven  that  these 


16  PRINCIPLES    OF    SURGERY. 

organs,  such  as  the  kidneys,  skin  and  bowels,  eliminate  disease 
germs,  as  you  can  inoculate  an  animal  with  the  urine  or  feces  of  a 
patient  suffering  from  Scarlet  or  Tj^phoid  fever  and  produce  the 
disease.  The  old  physicians  called  these  discharges  ^^  Critical  dis- 
oharges,''^  but  did  not  understand  it;  but  it  is  now  proven  by  the 
germ  theory,  as  in  a  case  of  typhoid  fever,  when  the  patient's  life 
is  almost  despaired  of,  the  kidneys  will  sometimes  commence  to  act 
freely,  and  the  patient  recovers.  So  now  we  know  thai  the 
"  Critical  discharges^-  of  the  old  physician  is  nature  trying  to  elimi- 
nate the  germs  which  has  overpowered  her  advance  guards,  the 
Phagocyte. 

The  Study  of  Bacteria.  —Bacteria  are  studied  Microscopically 
by  cultivation  and  by  inoculation.  It  has  only  been  by  recent 
inventions  that  we  are  able  to  study  bacteria  microscopically.  At 
firs-t,  owing  to  the  minuteness  of  the  organism  and  the  imperfec- 
tion of  Ihe  instruments,  small  progress  was  made;  but  with  the 
advent  of  Abbe's  condenser,  which  gives  powerful  illumination  to 
the  section  and  allowing  the  use  of  high  power  lens  their  study  is 
very  easy.  Then,  by  a  process  of  staining,  we  can  readily  distin- 
guish them.  By  the  use  of  aniline  dyes  we  stain  the  section,  and 
then  by  washing  with  alcohol  we  can  remove  the  stain  from  the 
tissue,  but  on  account  of  the  strong  affinity  for  dyes,  which  the 
bacteria  possess,  they  are  unaffected,  or  we  can  further  use  con- 
trast stains,  and  so  give  the  germs  a  blue  color,  the  cells  a  yellow 
color  and  the  tissues  black;  and  in  this  way  we  can  study  their 
shape,  motion,  mode  of  reproduction  and  in  this  way  learn  to  dis- 
tinguish one  from  another. 

The  cultivation  of  bacteria  is  carried  on  in  test  tubes.  In  culti- 
vating them,  remember  they  are  plants  and  for  their  growth  require 
a  suitable  soil,  warmth  and  moisture,  under  these  conditions  they 
grow  rapidly.  The  best  soil  or  media  is  animal  broth,  solution  of 
sugar,  gelatin,  blood  serum  and  agar  agar^  the  latter  a  jelly-like 
substance  obtained  from  seaweeds.  The  media  is  first  heated  to 
kill  any  germs  that  may  be  in  it,  then,  with  a  clean  needle,  secure 
your  germ,  touch  the  media,  close  the  tube,  put  it  in  an  incubator, 
and  in  a  short  while  you  will  have  millions  of  germs.  According 
to  Cohn,  during  one  day,  a  single  coccus  will  proauce  16,000,000, 
at  the  end  of  the  second  day   281,000,000,000.      Some  give  to  the 


PRINCIPLES    OF    SURGERY.  17 

media  a  red  color,  others  blue,  etc.,  and  a  skilled  observer  can 
recognize  the  specie  by  the  manner  in  which  they  grow  and  the 
color  given  to  the  media.  Much  inform atlon  concerning  bacteria 
has  beeo  obtained  by  inoculating  or  injecting  them  under  the  skin 
of  animals  and  noting  their  effect.  An  animal  is  taken  (rat,  guinea 
pig  or  rabbit)  and  the  hair  is  shaved  offj  the  sLin  disinfected,  so  as 
to  be  sure  you  do  not  implant  any  other  germ,  and  a  solution  of 
the  germs  is  then  injected  under  the  skin  with  a  hypodermic 
syringe,  or  an.  Incision  is  made  in  the  animal  and  a  piece  of  the  in- 
fected tissue  is  implanted ;  in  three  or  four  days  the  symptoms  of  the 
specific  disease  the  germs  experimented  with  produces  will  be  ap- 
parent,- and  in  case  of  virulent  diseases  the  animal  dies.  This  pro- 
cess is  of  great  aid  to  the  surgeon  in  making  a  diagnosis;  his  patient 
may  show  a  tumor,  and  a  positive  diagnosis,  whether  due  to  syphi- 
lis or  tuberculosis,  can't  be  made;  inoculation  gives  him  a  certain 
diagnosis,  he  takes  one  of  the  lower  animals,  puts  a  small  piece  of 
the  tumor  in  its  cellular  tissue,  if  the  tumor  is  syphilitic,  the  ani- 
mal will  show  no  symptoms,  as  man  alone  possesses  the  distinction 
of  this  disease;  but  if  it  be  of  tubercular  origin,  the  characteristic 
symptoms  are  soon  displayed. 

Isolation  or  Yakioits  Bacteria. — Certain  diseases  are  produced 
by  a  certain  germ  ;  the  germ  of  tuberculosis  always  produces  tuber- 
culosis, the  germ  of  pneumonia  always  produces  pneumonia,  the 
germ  of  typhoid  fever  always  produces  typhoid  fever,  etc.,  and 
Koch,  by  his  experiments,  has  set  forth  these  four  laws  as  invari- 
ably true;  and  before  a  germ  can  be  said  to  produce  a  disease 
they  must  be  fulfilled, 

1.  The  geim  must  invariably  be  found  accompanying  the  disease. 

2.  When  the  aniiral  dies  you  must  be  able  to  breed  the  germs 
in  a  test  tube,  and  by  successive  cultivations  entirely  remove  all 
the  tissue  of  the  animal  from  which  they  were  obtained. 

3.  You  must  be  able  to  reproduce  the  disease  in  another  animal 
tvith  the  cultivated  germs, 

4.  When  this  animal  dies  you  must  be  able  to  find  the  same 
germs  in  its  tissue  that  were  originally  used. 

Attenuation:  axd  Axtago2s'is:!j:  or  Bactekia. — The  germs  of  differ- 
ent diseases  have   been  subjected  to  all  sorts  of  tests,  tried  under 
all  sorts  of  conditions,  in  order  to  learn  their  peculiarities.      Many 
2 


18  PRINCIPLES    OF    SURGERY. 

strange  facts  have  been  learned.  One  is  that  bacteria  of  great 
virulence  can  be  rendered  weak  and  comparatively  harmless  by 
breeding  them  under  adverse  conditions,  just  as  the  Bushman  of 
Africa  has  been  deteriorated  by  existing  for  years  undv^r  debilita- 
tino:  climatic  conditions.  Aaother  curious  fact  is,  that  certain 
species  of  germs  have  violent  antipathy  for  each  other,  and,  if 
placed  in  the  same  media,  will  devote  all  their  energies  to  a  con- 
flict, and  it  is  only  after  one  species  has  extern: inated  the  other 
that  multiplication  begins.  The  practical  usefulness  of  these  ob- 
servations is  obvious,  for  already  are  ^e  attempting  to  cure  cancer 
with  the  germ  of  erysipelas  owing  to  their  antagonism. 

Theory  of  Immunity  and  Peedisposition  to  Disease. — It  has 
been  observed  that  some  people  ''''catch  diseases'''  easily,  that 
others  never  take  them  at  all,  that  some  people  have  a  predis- 
position to  disease,  and  others  an  immunity  to  it.  This  is  ex- 
plained by  the  face  that  a  person  who  has  a  tendency  to  acquire 
every  disease  to  Tvhich  he  is  exposed  has  blood  and  tissues  which 
have  feeble  resisting  power,  which  presents  a  favorable  soil  to  the 
growth  and  development  of  germs.  A  person  who  does  not  ac- 
quire disease  to  which  he  is  exposed  has  blood  and  tissues  which 
have  strong  resisting  power,  which  presents  an  unfavorable  soil  to 
the  growth  and  development  of  germs. 

Theories  of  Fkotection. — One  attack  of  many  microbic  diseases, 
such  as  smallpox  or  scarlet  fever,  prevents  a  subsequent  develop- 
ment of  the  jjame  disease.  This  is  explained  by  the  fact  that  each 
germ  requires  a  special  food  to  support  its  life  and  vitality;  that 
when  it  oDce  infects  an  organism  it  consumes  all  of  the  special  food 
the  blood  contains;  that  this  special  food  is  never  replaced,  and 
that  owing  to  its  absence  the  germ  cannot  again  maintain  an  exist- 
ence in  the  organism. 


( 


PRINCIPLES    OF    SURGERY.  19 


LKCTTJRE  IV. 


IXFLAMMATIOIS^. 

Intkoductory  Physiology. 

The  Blood. — The  blood  is  the  most  important  constitueat  of  the 
bed}'-.  It  is  the  means  bj  which  ail  the  tissues  are  directly  oc  indi- 
rectly nourished,  and  is  also  the  means  by  which  the  nraterial 
resulting  from  the  metabolism  of  the  tissue,  as  are  of  no  further 
use  in  the  economy,  are  carried  to  the  ecretory  organs  to  be  re- 
moved from  the  body.  It  also  serves  to  moisten  and  warm  the 
body.  Ic  is  composea  of  Blood  plasma  and  Blood  corpuscle.  The 
blood  plasma  is  the  fluid  portion  of  the  blood,  it  is  a  clear,  yellow, 
alkaline  fluid,  specific  gravity  1,020.  The  blood  corpuscles  rep- 
resent the  solid  element  of  the  blood,  and  are  of  three  kinds — 
White,  Eed  and  the  third  blood  corpuscle,  or  blood  plates.  The 
White  blood  corpuscles,  are  to  pathologist  the  most  important.  They 
are  round  or  spherical  nucleated  mass  of  protoplasm,  having  no  in- 
vesting membrane  or  cell  wall,  and  is  about  l-2500th  of  an  inch  in 
diameter.  Its  shape  is  retained  by  a  delicate  skeleton,  made  up  of 
a  reticulum  of  protoplasm.  They  possess  two  very  important  func- 
tions, both  of  which  depend  on  its  power  of  'changing  its  shape, 
viz. :  Amoeboid  movement  and  phagocytosis.  These  endowments 
are  accomplished  by  the  hyaline  strings  of  the  reticulated  skeleton, 
which  not  only  gives  shape  to  the  cell,  but  is  endowed  with  muscle- 
like contraction.  In  contracting,  an  arm  is  thrown  out  and  re- 
tracted, another  is  thrown  out  and  retracted,  oc  the  whole  cell 
may  flow  into  it,  thus  changing  its  position  and  accomplishing  what 
is  called  Amoeboid  movement.  Phagocytosis  is  accomplished  much 
in  the  same  way,  it  throws  out  an  arm  on  each  side  of  a  germ  or 
diatom,  the  arms  meet  and  so  encloses  it,  it  then  either  digests  and 
assimulates  it  or  it  remains  in  the  cell  as  a  foreign  body. 

The  red  corpuscles  are  much  more  numerous  than  the  white,  in 
a  normal  state  of  health,  the  proportion  being  about  1  white  to  500 
red  corpuscles.     The  red  corpuscle  is  a  round,  biconcave  disk,  with- 


20  PRINCIPLES    OF    SURGERY. 

out  a  nucleus,  when  viewed  singly  it  is  yellow,  but  are  red  '■'■en 
masse.''''  It  is  composed  of  a  colorless,  structureless  and  trans- 
parent filmy  framework  or  stroma,  which  is  infiltrated  in  all  parts 
with  haemoglobin.  It  does  not  possess  the  function  of  amoeboid 
movement  or  phagocytosis. 

The  third  blood  corpuscle  or  blood  plates,  have  only  been  de- 
monstrated in  the  last  fifteen  years.  They  are  much  more  numerous 
than  the  red  corpuscles,  are  round,  slightly  colored,  and  much  smaller 
than  the  red  corpuscle  and  contains  no  nucleus.  It  was  first 
thought  to  be  a  red  corpuscle  in  infancy,  but  this  theory  has  been 
abandoned,  as  w  e  now  know  that  the  red  corpuscle  is  thrown  into 
the  vessels  fully  developed  from  the  red  marrow  of  bones.  The 
function  of  the  third  corpuscle  is  the  production  of  a  clot,  as  they 
carry  all  the  ingredients  necessary,  so,  in  reality,  they  act  as  a 
guard  against  hemorrhage. 

The  Circulation. — The  circulation  may  be  described  as  the  pas- 
sage of  blood,  forced  or  pumped  by  the  heart  through  the  vessels  to 
every  part  of  the  body.  The  heart  is  provided  with  valves  to  pre- 
vent regurgitation,  and  by  its  powerful  contraction  the  blood  is 
sent  first  through  arteries,  capillaries,  and  then  through  the  veins 
back  again  to  the  rio:ht  side  of  the  heart.  JSTow,  as  inflammation  is 
so  intimately  connected  with  the  circulation,  we  must  study  the 
structure  of  the  tubes  through  which  the  blood  flows.  The  arteries 
are  formed  of  three  coats,  superimposed  one  on  the  other;  we  have, 
first,  the  inner  coat  or  Tunica  lotima;  second,  middle  coat  or 
Tunica  Media;  and,  third,  outer  coat  or  Tunica  Adveotitia.  The 
tunica  intima  is  maHe  up  of  layers  of  elastic  tissue  lined  by  endo- 
thelia  cells;  the  tunica  media  is  made  up  of  muscular  tissue,  and 
the  tunica  adventitia  is  made  up  of  dense  connective  tissue  and  is 
the  strongest  and  toughest  of  all  the  coats.  The  arteries,  then, 
are  seen  to  be  dense,  thick,  impermeable  tubes,  not  even  are  their 
own  walls  supplied  by  the  blood  they  carry,  but  by  small  arterioles 
called  '■'■vasa  vasorum."'  A-S  the  arteries  approach  the  capillaries, 
their  "walls  become  thinner  and  thinner,  until,  when  they  are 
reached,  they  are  composed  only  of  one  layer  of  large  endothelia 
cells,  which  are  so  thin  that  the  blood  f  lasma  goes  in  and  out  the 
vessels  and  so  supplies  the  tissues  with  nutriment.  The  study  of 
the  capillary  walls  is  facilitated  by  staining  them  with  nitrate  of 


PRINCIPLES    OF    SURGERY.  21 

silver,  when  the  cell  will  be  seen  to  be  placed  edge  to  edge  and 
held  together  by  an  amorphous  cement  substance,  and  at  regular 
intervals  very  small  openings  are  seen  between  the  cells,  called  by 
Arnold  ^^ stigmata.'''  The  capillaries  run  into  veins,  whose  coats 
again  commence  to  thicken  and  become  impermeable,  until  in  the 
large  veins  the  three  coats  of  the  arteries  are  assumed.  If  a  sec- 
tion of  tissue  be  put  under  the  microscope  and  the  current  of  blood 
watched  in  the  vessels,  two  currents  will  be  seen,  one  in  the  middle 
called  the  Axial  current,  the  other  near  the  wall  of  the  vessel  called 
the  Peripheral  current.  Both  currents  run  tbe  same  direction,  but 
the  axial  current,  in  which  flows  the  red  corpuscles,  is  about  ten 
times  as  fast  as  the  peripheral  current,  in  which  the  white  cor- 
puscles and  blood  plates  flow.  These  two  currents  exist  in  any 
fluid  pumped  through  an  elastic  tube,  therefore  they  must  exist  in 
the  arteries,  capillaries  and  veins. 

Inflammation. — -To  define  the  term  is  diBBcult,  but  probably  the 
best  is  given  b}^  Sanderson,  as  follow  :  ^ '•  Inilammation  consists  of  a 
series  of  a  histological  changes  ichich  occur  in  limng  tissue  when  it 
is  injured.^  provided  the  injury  is  not  sufficient  to  immediately  de- 
stroy its  vitality. 

Causes. — There  has  been  held,  as  the  cause  of  inflammation,  for 
many  years,  three  theories,  the  last  of  which  is  the  most  modern. 
1.  Traumatic;  2.  Chemical;  3.  Microbic.  A  blow,  stab,  cut  or 
sprain  is  a  specie  of  traumatism  ;  burns  of  a  match,  nitric  acid,  etc., 
is  chemical.  But  the  modern  surgeons  exclude  the  above  as  causes 
of  inflammation  and  nanae  them  onh''  as  exciting  or  predisposing 
causes,  creating  a  place  in  which  the  germ  may  locate-  and  cause 
the  trouble.  Xinety-nine  per  cent,  of  suppuration  inflammation  is 
caused  by  a  microbe  (Senn  only  gives  the  microbe  as  the  cause). 

Fathology. — To  study  the  processof  inflammatiDU  the  following 
artiflcial  method  has  been  instituted.  A  frog  is  taken  and  three 
or  four  minims  of  curara  is  injected  subcutaneously,  this  does  not 
interfere  with  the  circulation,  but  causes  paralysis  immediately. 

Make  a  small  slit  in  his  belly,  draw  out  the  intestines  and  irri- 
gate them  with  nitrate  of  silver,  place  under  the  microscope  and 
the  changes  can  be  readily  foUo^ved.  When  ycu  first  look  every- 
thing will  be  normal.  1.  As  soon  as  inflammation  commences  the 
blood  vessels  dilate,  and  the  flow  of  blood  is  accelerated,  due  to 


22  PRINCIPLES    OF    SURGERY. 

stimulation  of  the  vaso -dilator  nerves,  this  is  the  stage  of  Hyperae- 
mia.  2.  The  vessels  continue  to  dilate  until  their  walls  are  para- 
lyzed from  overdistention,  the  current  becomes  slower,  caused  by 
more  blood  coming  to  the  part  than  can  be  carried  off  bj^^  the  veins, 
this  is  the  stage  of  Congestion.  3.  In  a  short  while  the  current 
ceases,  due  to  the  plugging  up  of  the  veins  by  the  white  corpuscles 
accumulating  in  large  numbers,  and  there  is  stagnation  called  the 
stage  of  Stasis.  "With  thpi  stage  of  hyperaemia  the  red  corpuscles 
remain  in  the  axial  current  and  the  white  corpuscles  in  the 
peripheral  current,  but  with  the  stage  of  congestion  it  is  observed 
that  the  red  corpuscles  also  go  to  the  periphery.  The  white  cor- 
puscles next  become  glutinous  and  adhere  to  the  wall,  and  another 
will  come  along  and  knock  it  off,  as  if  trying  to  keep  up  the  flow, 
but  they  finally  adhere  to  the  wall  in  such  numbers  as  to  cause 
complete  stoppage,  and  we  have  the  stage  of  stasis. 

In  inflammaLion  there  is  always  swelling,  due  to  accumulation  of 
the  blood  in  the  tissues,  which  escapes  at  the  same  time  the  fore- 
going phenomena  are  taking  place.  The  constituents  of  the  blood 
go  through  the  vessels  wall  by  two  processes — Transudation  and 
Exudation.  Transudation  is  the  escape  of  the  fluid  element  of  the 
blood  by  percolation.  Exudation  is  the  escape  of  the  corpuscular 
element,  and  is  a  much  more  complicated  process:  as  inflaiimation 
progresses  the  stigmato  grows  larger,  a  white  corpuscle  will  stop 
at  one  of  them  and  will  finally  work  its  way  through  by  emigra- 
tion, stretching  the  hole  larger  and  then  the  red  corpuscles  escape 
b}'-  diapedesis.  Although  the  white  corpuscle  is  larger  than  the 
red,  it  goes  throught  first,  and  it  does  so  by  virtue  of  its  ameboid 
movement.  Sometimes  a  rent  is  made  in  the  wall  of  the  vessel  large 
enough  for  a  quantity  of  blood  to  escape,  which  constitutes  a 
hemorrhao^e  and  is  called  Rliexis. 


PRINCIPLES    OF    SURGERY.  23 


LECTURE  V. 


IXFLAMMATION.— CoNTmuEi). 

Symptoms. — General.- — These  are  due  to  the  absorption  of  the 
toxins  into  the  system,  which  toxins  ate  the  product  of  the  germ 
which  caused  the  inflararaatioa.  There  is  a  chill,  followed  by  fever, 
headache,  weakness  and  nausea. 

Local. — The  classification  of  the  local  symptoms,  enumerated  by 
Celsus  500  years  ago,  is  still  recognized  as  the  best.  He  gave  five 
cardinal  symptoms: 

1.  Dolar — pain. 

2.  Calor — heat. 

3.  Rubor — redness. 

4.  Tumor — swelling. 

5.  Functio  laesa — impaired  function. 

Intiammatioa  is  invariably  accompanied  by  pain,  which  is  caused 
by  pr assure  on  the  nerves  or  by  direct  inflammation  of  the  nerve 
filaments.  The  intensity  of  the  pain  varies  under  certain  condi- 
tions; it  will  le  more  intense,  everything  else  being  equal,  in  parts 
richly  supplied  by  nerves,  than  in  a  part  with  poor  innervation;  it 
is  less  in  parts  that  are  elastic  and  loose,  because  v^hen  the  exuda- 
tions are  poured  out  the  tissue  can  give  away  and  thus  lessen  the 
pressure  it  would  produce.  The  character  of  the  pain  differs  in 
different  individuals,  and  in  the  same  individual  according  to  the 
location  of  the  inflammation,  as  in  inflammation  of  the  skin,  the  pa- 
tient will  say  the  pain  is  burning;  in  peritonitis,  it  is  darting;  in  the 
bone,  it  is  gnawing,  and  in  loose  connective  tissue,  it  is  throbbing. 
It  differs  accordino;  to  the  anatomical  tissue  involved,  the  location 
of  the  pain  is  generally  at  the  seat  of  inflammation,  but  in  rare  in- 
stances it  is  referred  from  the  seat  of  inflammation  by  the  nerves 
elsewhere,  as  in  Pott's  disease  of  the  spine  the  pain  is  located  in 
the  stomach,  instead  of  in  the  back;  in  hip  joint  disease  the  inflam- 
mation is  in  the  acetabular  cavity,  but  the  pain  is  referred  to  the 
knee  and  it  is  often  treated  for  rheumatism  of  the  knee  joint. 
These  symptoms  are  spontaneous,  but  there  is  also  tenderness  on 


24  PRINCIPLES    OF    SURGERY. 

pressure  about  the  part  inflamed,  which  is  a  great  help  in.  making 
a  diagnosis,  as  the  surgeon  cannot  only  make  out  the  seat  of  in- 
flamrcation,  but  can  tell  the  extent  to  which  it  has  progressed. 
The  differeace  between  a  neurotic  pain  and  an  inflammatory  pain 
is  that  the  neurotic  pain  is  relieved  on  pressure,  and  the  pain  of 
inflarrimation  is  intensified. 

Redness  is  a  most  natural  sequence  and  is  caused  by  the  increased 
airount  of  blood  to  the  part.  The  color  varies  with  the  different 
stages;  in  the  stage  of  hyperaemia  the  part  is  of  a  bright  scarlet 
hue  of  arterial  blood,  and  in  the  stages  of  congestion  and  stasis  the 
blood  is  dammed  back,  and  the  part  assumes  the  blue  color  of  ven-  ' 
ous  blood.  Swelling  invariably  accompanies  inflammation.  It  is 
caused  by  the  ditalation  of  the  blood  vessels,  the  escape  of  the  fluid 
element  of  the  blood  by  transudation.,  and  is  further  increased  by 
the  exudation  of  the  corpuscular  elements  of  the  blood. 

The  heat  of  the  body  is  generated  largely  in  the  muscles  and 
glands,  and  is  conveyed  to  all  parts  of  the  body  by  the  blood.  This 
symptom  of  heat  in  inflammation  is  wefl  represented  by  the  boiler  in 
a  house.  From  the  boiler  in  the  basement  the  steain  is  general  ed 
and  is  carried  to  the  different  rooms  by  pipes,  the  quantity  of  heat 
in  the  rooms  depends  upon  the  amount  of  steam  passing  through 
the  pipes,  so  with  the  tissues  in  inflammation,  the  amount  of  blood 
to  the  part  is  increased  and,  consequently,  the  heat  is  also  in- 
creased, but  never  above  the  maximum  temperature  of  the  blood. 
This  symptom  is  of  diagnostic  value;  by  it  we  can  tell  whether  the 
swollen  part  covers  a  malignant  tumor  or  is  the  seat  of  some  in- 
flan,matory  trouble,  a  surface  thermometer  being  applied  to  the 
part. 

Deranged  function  ma}^  be  in  a  direction  of  increased  or  dimin- 
ished physiological  activity,  as  in  inflammation  of  a  joint— as  the 
knee  renders   that  joint  useless,  whereas  in  the  inflammation  of  a 
mucous  surface,  as  in  a  bad  cold,  the  function  of  secretion  is  in-  * 
creased  and  there  is  a  large  amount  of  mucous  poured  out. 

Termination. — Inflammation  may  terminate  by  Resolution,  Sup- 
puration or  Necrosis. 

Under  favorable  conditions  and  the  proper  treatment,  the  inflam- 
mation will  subside  and  the  parts  will  return  to  their  normal  con- 
dition; this  is  a  most  happy  termination  and  is  calied  termination 


PRINCIPLES    OF    SURGERY.  25 

by  resolution,  which  takes  by  the  removal  of  the  cause  of  the  in- 
flaramatioD ;  the  phagocytes  exterminates  the  germs  and  nature 
completes  the  cure  by  removing  the  exudations  and  transudations 
by  the  lymphatics-  But  suppose,  in  spite  of  everything  you  can 
do,  the  inflammation  goes  from  bad  to  worse,  the  site  of  the  pro- 
cess enlarges  and  at  one  point  assumes  a  purple  color,  gets  soft,  you 
then  hope  that  suppuration  will  occur,  you  v^'ait.  it  may  or  may  not 
occur,  bnt  instead  necrosis  takes  place,  and  you  have  sloughing, 
due  to  the  blood  being  entirely  cut  off  by  pressure  and  the  tissues 
die  from  want  of  food.  In  a  boil  you  find  what  is  called  a  "  Core,*' 
this  is  nothing  but  a  mass  of  tissue  which  has  undergone  necrosis. 

Diagnosis. — This  is  usually  simple.  The  diagnosis  is  not  based 
or  can't  be  depended  on  from  the  general  symptoms,  but  is  based 
on  the  local  symptoms,  especially  heat.  Heat  is  the  most  impor- 
tant symptom,  ana  without  heat,  although  there  may  be  all  the 
other  cardinal  symptoms,  3'"ou  do  not  have  inflammatioa. 

Pbognosis. — The  prognosis  is  based  on  1.  The  character  of  the 
cause;  if  it  be  caused  by  the  Gonococci,  the  prognosis  is  favorable, 
and  its  terminaticn  looked  for  in  two  or  three  weeks,  but  if  it  is 
caused  b\  the  bacilli  of  Tetanus,  the  prognosis  is  grave  and  the 
death  of  your  patient  expected.  2.  The  anatomical  tissues  in- 
volved, if  it  is  the  brain,  of  course,  it  will  be  more  grave  than  the 
tissues  on  the  back  of  the  neck;  if  it  be  the  vocal  cords,  it  will  be 
more  serious  than  an  infiaraed  ingrowing  toe  nail.  3.  General  con- 
dition of  the  patient:  Inflammation  occurring  in  a  very  feeble  old 
man  or  in  a  drunkard  or  in  a  person  with  lowered  vitality  from 
any  cause,  gives  a  more  grave  prognosis  than  wtien  occurring  in  a 
young,  robust,  temperate  individual.  4.  Accessibility  of  the  dis- 
ease to  surgical  treatment:  If  the  inflammation  be  of  the  mascoid 
cells,  which  can  onl}^  be  reached  by  a  very  dangerous  operation,  the 
prognosis  will  be  graver  than  a  boil  on  the  back  of  the  neck,  which 
is  readily  accessible  to  surgical  treatment. 


26  PRINCIPLES    OF    SURGERY. 


LKCTURE  VI. 


INFLAMMATIO]^.— Continued. 

Classification. — The  various  types  of  inflammation  are  not  due 
to  Siny  difference  in  their  pathological  changes,  but  to  difference  in 
the  intensity  of  these  respective  phenomena,  so  it  is  not  a  differ- 
ence in  kind,  but  in  decree. 

The  types  of  inflainraation  are  modified.  1.  B^j  cause:  As  in- 
flammation produced  by  the  germ  of  suppuration;  inflammation 
produced  by  the  germ  of  erysipelas,  etc.  2.  By  degree:  Acute, 
sub-acute  and  chronic  inflaramalion.  This  does  not  mean  that  there 
are  three  different  kinds  of  inflammation,  for,  in  fact,  they  are  so 
much  alike  that  it  is  only  in  their  onset  that  we  can  diagnose  one 
from  the  other.  We  speak  of  acute  inflammation  when  the 
symptoms  of  development  are  rapid,  this  is  a  very  dangerous  form. 
TV  hen  the  symptoms  of  development  are  slower  and  the  inflamma- 
tion lasts  two  or  three  v^eeks.  we  call  it  sub-acute  inflammation. 
When  the  sj/mptoms  develop  not  very  fast  or  very  slow  and  the 
inflammation  does  not  respond  to  treatment,  we  call  it  chronic  in- 
flammation. 3.  By  product:  In  inflammation  there  is  always 
transudation  and  exudatioc  of  the  eleirents  of  the  blood  into  the 
surrounding  tissue.  If  the  transudation  of  the  fluid  element  is 
greater  than  the  exudation  of  the  solid  element,  we  call  it  Inflarc- 
raator}^  transudate.  If  the  exudation  is  in  excess  of  the  transuda- 
tion, we  call  it  Inflammatory  exudate;  this  is  rarely  seen.  The 
difl'erence  in  the  amount  of  transudate  and  exudate,  which  is  noticed 
above,  is  due  to  some  peculiar  microbic  change  in  the  tissues.  In 
all  inflanimaticns  there  is  always  a  certain  amount  of  red  corpus- 
cles in  the  exudation,  but  not  in  such  quantities  as  the  white,  but 
occasionally  the  red  corpuscles  escape  in  greater  amounts  than  the 
white  corpuscles,  and  the  tissues  become  stained  a  bright  red,  and 
as  the  inflammation  subsides  the  haemoglobin  dries  in  the  tissues 
and  leaves  them  permanently  colored ;  no  explanation  can  be  offered 
for  this  increased  escape  of  red  corpuscles,  it  is  a  very  serious  con- 
dition and  is  called  Hemorrhagic  Inflammation,     In  some  instances 


PRINCIPLES    OF    SURGERY.  27 

the  elements  of  the  blood  which  aie  thrown  out  into  the  tissues  be- 
come pus,  the  transudate  forming  fluid  pus,  the  exudate  forming 
pus  corpuscles;  this  is  called  Suppurative  inflammation  and  will  be 
treated  of  in  a  subsequent  lecture.  4.  By  variety  of  tissue  pri- 
tnarily  effected,  (a)  Non-vascular  tissue.  We  know  there  are  cer- 
tain tissues  in  the  bod}'  which  are  non- vascular,  and  derive  their 
nutrition  by  percolation  of  lymph  from  surrounding  arterioles.  The 
cornea  c;.nd  cartilage  is  an  example  of  such  non -vascular  tissue. 
]S'o\v  remembering  the  pathology  of  inflammation,  we  note  that 
the  first  changes  affected  the  blood  vessels;  now  as  in  the  cornea, 
where  we  have  no  blood  vessels,  h^w  does  inflammation  occur?  It 
occurs  in  this  way:  If  you  irrigate  the  cornea  with  nitrate  of  sil- 
ver, which  results  in  inflammation,  we  will  notice  that  the  blood 
vessels  encircling  the  cornea  becomes  dilated,  and  the  lymph  and 
white  corpuscles  escape,  with  the  result  that  the  lyrcph  spaces  are 
found  packed  with  them;  soon  new  blood  vessels  will  form  from 
these  vessels  and  extend  to  the  cornea,  and  the  inflammation  pro- 
ceeds as  before  described.  If  resolution  takes  place,  the  newly 
formed  bloodvessels  shrink  and  finally  disappear,  leaving  the  sight 
uninjured,  but  if  suppuration  occurs  the  vessels  are  not  obliterated 
and  the  sight  remains  permanently  injured.  In  cartilage,  which 
is  still  more  poorly  supplied  with  blood,  the  process  is  almost  iden- 
tical. When  irrigated  with  Silver  nicrate,  the  vessels  in  the  peri- 
chondrium becomes  dilated  and  throws  out  lymph  and  white  cor- 
puscles, and  the  new  vessels  then  form  from  the  vessels  in  the  peri- 
chondrium and  extends  to  the  cartflage  and  inflammation  then  pro- 
ceeds as  before  described,  (b)  Vascular  tissue.  The  spleen  and 
liver  is  an  esarcple.  These  glands  are  made  up  of  cells  \^hich 
elaborate  their  secretions  and  are  called  Parenchymatous  tissue; 
they  are  divided  off  into  lobes  and  lobules  by  fibrous  tissue,  which 
is  called  Interstitial  tissue.  When  inflammation  first  attacks  the 
specific  fecreting  cells  of  a  gland  it  is  called  Parenchymatous  in- 
flammation, and  the  cells  soon  disintegrate,  causing  death.  When 
inflammation  attacks  the  fibrous  septa  first,  it  is  called  Interstitial 
inflammation,  and  the  organ  soon  becomes  hard  and  firm.  It  is  ditfi- 
cult  to  tell  which  portion  of  an  organ  is  first  attacked,  for  in  pa- 
renchymotous  inflammation  the  interstitial  is  soon  also  set  up  and 
vice  versa.     When  inflammation  attacks  serous  surfaces  as  the  peri- 


28  PRINCIPLES    OF    SURGERY. 

toneum,  pleura  or  synovial  membrane,  it  is  called  Serous  inflam- 
mation; this  may  follow  several  different  types,  as  Effusive  Se- 
rous inflammation,  this  is  caused  by  the  effusion  of  the  fluid  ele- 
ment of  the  blood,  accompanied  by  very  little  of  the  solid  element. 
This  is  well  seen  in  serous  inflammation  of  the  knee  joint,  when  a 
large  amount  of  serum  surrounds  the  joint;  Adhesive  Serous  in- 
flammation, this  is  when  the  solid  elements  escape  in  greater 
amounts  than  the  fluid  element,  the  surface  of  the  membrane  be- 
comes coated  ^ith  the  corpuscles,  causing  them  to  adhere;  Sup- 
purative serous  inflammation  is  merely  a  later  stage  of  either  of 
the  preceding  varieties,  caused  by  the  pyogenic  microbe. 

"When  the  mucous  surfaces  are  attacked  by  inflammation,  it  is 
called  Mucous  inflammation,  and  may  follow  three  types.  When 
any  mucous  surface  is  attacked  by  inflammation,  causing  an  in- 
creased amount  of  mucous  to  be  secreted  (as  in  a  bad  cold),  it  is 
called  Mucous  Catarrhal  inflammation;  if  this  goes  on  to  the  for- 
mation of  pus  it  is  called  Suppurative  Mucous  inflammation,  and 
when  a  membrane  is  formed  on  the  mucous  surface  it  is  called 
Croupous  inflammation.  This  form  often  attacks  the  nose  and 
bladder,  but  is  best  seen  in  diphtheria.  There  is  no  difference  be- 
tween Membranous  Croup  and  Diphtheria,  both  are  due  to  a  germ 
which  produces  the  membrane  by  coagulating  the  fibrin  of  the  blood. 


LECTURE  VII. 


liSTFLAMMATIOT^.— Continued. 

Treatment. — The  principle  method  of  treatment  of  inflammation 
a  generation  ago  was  the  so-called  Antiphlogistic  treatment.  This 
method  *vas  based  on  the  phlogistic  theory,  which  was  tliat  inflam- 
mation was  an  inflammable  condition  of  the  tissues,  and  must, 
therefore,  be  treated  Oy  depleting  the  system,  which  was  accom- 
plished by  vivisection,  cupping,  leeching  and  the  administration  of 
emetics  and  purgatives.     These  remedies  are  used  at  the  present 


PRINCIPLES    OF    SURGERY.  29 

time,  but  not  vMth  the  same  end  in  view,  as  we  now  understand 
the  cause  of  inflammation,  which  the  older  surgecms  were  ignorant 
of.  The  Antiphlogistic  treatment  has  now  almost  entirely  been 
succeeded  by  the  Antiseptic  treatment,  which  has  the  advantage 
of  dealing  directly  with  the  cause  of  the  inflammation,  which  is 
a  germ.  The  Modern  treatment  can  be  divided  into  the  Prophy- 
lactic and  (yurative.  The  former  is  preventioa  of  infection,  which, 
is  accomplished  b}^  the  surgeon  having  his  hands,  instraments  and 
dressings  aseptic.  The  latter  is  the  application  of  remedies  where 
bacterial  infection  has  already  taken  place  and  may  be  divided  into 
Local  and  Constitutional. 

Local  Treatment. — -This  consist  in  ihe  application  of  remedies 
with  the  view  of  relieving  pain,  lessening  the  swelling  and  as  sooth- 
ing applications.  1.  Bleeding.  Venesection  was  very  much  prac- 
ticed in  the  antiphlogistic  treatment,  but  is  scarcely  ever  resorted 
to  now,  for  by  bleeding  the  arterial  tension  is  dimirished,  and  so 
the  "7j25-«-z!er^(9, "thereby  lessening  the  chance  of  a  favorable  ter- 
mination by  resolutioQ,  Direct  abstraction  of  blood  may,  under 
certain  conditions,  be  used  to  advantage:  when  the  iaflammation 
is  superficial  and  the  part  tense  and  swollen,  it  relieves  the  pain  by 
lessening  the  pressure,  but  should  only  be  resorted  to  in  the  stage 
of  Hyperaemia.  Leeches  were  at  one  time  used,  but  on  account 
of  the  liability  of  their  infecting  the  wound  they  are  no  longer 
used.  The  safest  way  of  abstracting  blood  is  to  cut  down  to  the 
capillaries  with  a  clean  scalpel,  and  then  increase  the  flow  by  cup- 
ping or  by  the  application  of  waim  antiseptic  solutions. 

2.  Counter  irritants.  These  are  useful  in  some  cases,  especially 
when  the  inflammation  is  of  a  chronic  variety.  The  remedies  most 
frequently  used  are  Tr.  Iodine,  Actual  cautery  and  blisters.  These 
remedies  were  largely  used  in  the  antiphlogistic  treatment,  but  are 
rarely  used  at  the  present  time, 

3.  Compression.  This  is  a  valuable  remedy  in  the  treatment  of 
both  the  early  and  late  stages;  it  mast  bft  applied,  however,  in  the 
acute  stage  with  great  care,  as  sloughing  or  even  gangrene  may  be 
the  result  of  tight  bandages  on  a  part  when  the  circulation  is  al- 
ready enfeebled  by  injury,  but  if  properly  applied  it  restrains  the 
tendency  to  excessive  swelling  and  to  the  collection  of  serous  or 
bloody  discharges  between  the  lips  of  the  wound.     In  the  late  or 


30  PRINCIPLES    OF    SURGERY. 

chronic  stage,  it  is  the  best  remedy  we  possess  to  promote  absorp- 
tion and  resolution.  A  most  eiBcient  means  of  obtaining  compres- 
sion of  a  part,  espeoially  the  knee  joint,  is  compressed  sponges. 
Two  coarse  sponges  may  be  flattened  over  night  under  a  heavy 
piece  of  furniture,  one  of  them  is  then  applied  to  each  side  of  the 
joinr,  which  is  put  un  a  posterior  s{:lint,  a  long  cotton  bandage  is 
then  applied,  after  which  a  stream  of  water  is  allowed  to  trickle 
on  the  sponges,  which  makes  them  swell  and  so  causing  compies- 
siou. 

4.  Cold.  Cold  is  useful  in  certain  stages  and  harmful  in  others. 
It  is  onl}^  useful  in  the  early  stages,  when  the  vessels  are  dilated 
and  slightly  obstructed,  and  still  more  appropriate  when  the  inflam- 
mation is  superficial.  It  produces  constriction  of  the  vessels  and 
also  has  an  inhibatory  influence  on  the  bacteria.  It  should  never 
be  used  in  the  later  stage,  as  it  interferes  with  the  formation  of  the 
collateral  circulation  and  produces  pain  and  discomfort.  It  may 
be  applied  either  by  evaporating  lotions  or  by  the  use  of  ice,  ap- 
plied either  in  a  rubber  bag  or  fcy  the  coil,  by  which  a  current  of 
ice  water  is  allov^ed  to  flow  through  a  rubber  or  metal  coil  over 
the  part.  Care  must  be  taken  to  avoid  freezing  and  thus  causing 
sloughing. 

5.  Heat.  Heat  acts  as  a  counter-irritant  and  also  on  the  circu- 
lation, relieving  stasis  and  favoring  absorption  of  the  exudation. 
Poultices  have  been  discarded  in  the  treatment  of  open  wounds  and, 
in  fact,  are  seldom  ever  used  at  the  present  time.  Heat  is  now  ap- 
plied as  antiseptic  fomentations  of  bichloride  mercury,  carbolic 
acid,  etc.,  if  the  inflammation  is  not  extensive  and  there  is  no  other 
contraindication,  but  in  old  people  with  extensive  inflammation, 
we  use  a  less  poisonous  drug,  as  boracic  acid.  Wring  out  a  piece 
of  flannel  from  the  hot  solutions,  apply  to  the  part,  place  over  it  a 
piece  of  oil  silk,  which  holds  the  heat.  In  this  you  have  all  the  good 
qualities  of  a  poultice  and  do  away  with  its  disadvantages — poul- 
tices are  hot  beds  for  bacteria. 

6.  Elevation.  By  elevation  through  the  force  of  gravity  the 
circulation  from  the  inflamed  point  is  assisted  and  the  supply  of 
blood  regulated^  in  this  manner  the  pain  and  swelling  is  relieved. 
This  is  especially  useful  in  inflammation  of  the  extremities. 

7.  Physiological  rest.     This  is  a  most  important  indication.     In 


PRINCIPLES    OF    SURGERY,  31 

inflammation  of  the  stomach,  when  food  can't  be  retained  or 
digested,  it  is  best  to  give  food  by  enema  and  let  the  stomach  rest. 
In  inflammation  of  the  pleura,  strap  the  side  with  adhesive  plaster. 
In  joint  inflammation  apply  a  splint.  A  chronic  cystitis  may  be 
cured  by  cystotomy  after  all  other  remedies  fail, 

8.  Parenchymatous  injection.  This  method  of  treatment  has 
been  suggested  to  arrest  the  progress  of  the  germ.  It  consists  of 
iujectmg  into  the  part  inflamed  an  antiseptic  solution,  as  carbolic 
acid  in  3  per  cent,  strength,  and  the  amount  injected  to  be  regu- 
lated by  the  internal  dose.  It  is  a  dangerous  treatment  and  not 
much  employed. 

9.  Massage.  This  consist  in  rubbing,  kneading  and  manipula- 
ting the  part.  If  used,  a  skillful  operator  shculd  be  employea.  It 
can  only  be  used  in  chronic  cases,  as  in  acute  inflammation  the  pain 
would  be  too  great.  Medicated  ointments  may  be  rubbed  in,  and 
are  of  value;  a  solution  ot  Iodide  of  Potassium  in  alcohol  and  some 
oily  substance  is  recommended.  This  treatment  stimulates  the 
tissues  and  vessels,  ani  also  aids  in  the  absorption  of  the  inflam- 
matory productfi. 

Constitutional  Treatment. — It  is  essential  to  remember  that 
local  treatment,  whatever  its  nature  may  be,  is  not  the  only 
method  to  bo  employed  to  restore  your  patient  to  health,  and  a 
careful  surgeon  will  always  pay  due  attention  to  the  general  health 
of  his  patient  and  will  not  let  the  presence  of  organic  disease  else- 
where be  undiscovered.  By  the  use  of  cocstitutional  remedies  you 
assist  nature  in  subduing  the  inflaramation. 

1.  Stimulants.  Instead  of  the  old-time  treatment,  when  inflam- 
mation and  fevers  were  starved,  it  is  now  the  accepted  method  to 
stimulate  and  build  up  the  patient  in  every  possible  way.  Stimu- 
lants, such  as  whiskey,  champagne  and  sherry,  can  be  administered 
from  the  onset  of  an  acute  inflammation,  unless  the  patient  is  sink- 
ing rapidly,  when  musk  or  camphor  is  best,  acting  quicker  than 
the  former.  In  chronic  types,  and  when  the  stomach  refuses  the 
above,  use  beer^  ale,  etc.  Stirculants  must  be  given  in  doses  large 
enough  to  have  a  decided  action.  They  are  especially  useful  in 
fevers  to  sustain  the  strength,  as  'rtell  as  in  chronic  wasting  disease. 
In  these  diseases  stimulants,  such  as  whiskey  beer  and  ale,  act  as 
food,  and  it  is  well  to  note  that  they  can  be  taken  in  larger  quan- 
tities than  in  health. 


32  PRINCIPLES    OF    SURGEP.Y. 

2.  Antipyretics.  These  drugs,  such  as  Antipyrine,  Phenacetine, 
etc.,  may  somewhat  subdue  the  temperature,  but  they  also  have  a 
depressing  action  on  the  heart,  and  are,  therefore,  little  used  in 
inflammation.  The  best  means  to  lovver  the  temperature  is  by  the 
use  of  baths,  baths  not  only  lower  the  temperature,  but  are  refresh- 
ing, stimulating  and  also  favor  the  removal  of  the  poisons  excreted 
by  the  skin. 

3.  Purgatives.  Purgatives  vf  ere  freely  used  in  the  Antiphlogis- 
tic treatment,  and  are  still  found  valuable  in  certain  forms  of  in- 
flammation. They  are  a  part  of  the  routine  treatment  of  head  in- 
juries, and  if  administered  promptly  in  coma,  following  these  in- 
juries or  in  apoplexy,  they  are  supposed  to  remove  sources  of  irri- 
tation and  to  leave  the  system  in  a  condition  unfavorable  to  men- 
ingeal or  cerebral  inflammation.  Six  grains  of  calomel  placed  on 
the  tongue  and  followed  in  two  hours  by  aa  aloes  enemata  (Powd. 
aloes  one  drachm  to  one  pint  of  soapsudsj.  Such  a  mode  of  treat- 
ment is  supposed  to  exert  a  derivative  action  by  means  of  which 
irritation  is  removed  from  the  brain  aad  its  coverings  to  distant 
parts  of  the  economy.  The  tendency  to  hyperaemia  is  certainly 
diminished.  The  treatment  of  peritonitis  by  purgatives,  particu- 
larly after  a  laporotomy,  has  recently  come  into  vogue.  They 
seem  to  relieve  the  tympanitis,  and  by  their  production  of  watery 
stools  relieves  the  engorgement  of  the  intestinal  blood  vessels,  and 
they  also  eliminate  the  germs  or  their  toxins  by  causing  the  emptier 
vessels  to  absorb  the  peritoneal  exudates.  The  drugs  used  are  calo 
mel,  Epsom  salts  and  Seidlitz  potvders. 

4.  Diaphoretics.  Although  but  little  used  in  surgery,  diaphore- 
tics may  be  found  of  value,  owing  to  their  antipyretic  action. 
They  also  assist  the  elimination  of  poisons  by  the  skin,  and  as  a 
good  many  of  them  are  also  diuretics  they  increase  the  action  of 
kidneys.  Sweet  Spirits  of  JSTitre  and  v^ater  are  the  remedies  prin- 
cipally used. 

5.  Emetics.  Emetics  have  long  since  been  discarded  in  the 
treatment  of  inflammation,  but  were  used  freely  in  the  antiphlo- 
gistic treatment. 

6.  Anodynes.  Ths  use  of  anodynes  in  chronic  inflammation, 
where  the  pain  is  severe  and  recovery  not  looked  for  immediately, 
should  be  with  caution,  as  there  is  danger  of  the  patient  using  the 


PRINCIPLES    OF    SURGERY.  33 

drug  habitually  after  recovery.  They  are  of  great  service,  as  they 
relieve  the  pain,  which  is  the  worst  symptoriQ  of  inflammation. 
Morphine  is  a  good  preparation  to  use.  The  most  satisfactory 
mixture  for  inflammation  of  the  brain  is  Chloral  and  Bromide  of 
potassium  in  camphorated  oil. 

7.  Diet.  The  diet  is  of  the  greatest  importance.  The  patient 
should  have  plenty  of  highly  nitrogenous  and  easily  digested  food, 
so  as  to  retain  his  strength.  Give  a  liquid  diet,  such  as  animal 
broth,  beef  tea  and  milk,  if  the  digestion  is  impaired,  otherwise 
give  beef  steak  and  eggs.  When  the  stomach  can't  retain  food, 
give  by  rectum  every  four  hours,  four  ounces  of  peptonized  beef 
juice. 

8.  Tonics.  Quinine,  Tinct.  Iron,  Tmct.  ]^ux  Yomicaand  Strych- 
nine are  used,  and  are  of  great  value. 

9.  Specifics.  When  syphilis  is  the  cause  of  the  inflammation, 
give  Mercury  and  Iodide  of  Potash. 

R 

Hydrargyi'i  Bichlor  Cor.  griss  (i) 

Potassi  lodid  5iii  (3) 

Tr.  Gentianae  Comp.  §ii  (2) 

Aq  Dest  qs  ad  §iv  (4) 

M. 

Sig. :  Two  teaspoonfuls  after  meals.  When  rheumatism  is  the 
cause  give  salicylate  of  soda  and  bicarbonate  of  potassium.  When 
tuberculosis  is  the  cause  give  Arsenite  cf  Iron,  Syr.  Iodide  Iron 
and  Cod  Liver  oil,  pure,  if  patient  can  assimulate  it. 


LECTURE  VIII. 


PROCESS    OF   REPAIR. 

Regeneration.  — Regeneration  consists  of  the  process  by  which 
normal  physiological  waste  is  repaired  and  by  which  defects  in  tissues 
due  to  injury  are  restored.     It  is  divided  into  Physiological  and 

3 


34  PRINCIPLES    OF    SURGERY. 

Surgical  regeneration.  Physiological  regeneration  is  the  process 
by  which  normal  physiological  waste  is  repaired.  We  learn,  from 
the  study  of  Physiology,  that  the  cells  ot:  the  body  do  not  have 
long  life  (some  authors  claim  that  the  body  is  reconstructed  every 
seven  years),  so  after  a  certain  time  the  cells  die  and  are  rubbed 
off  from  the  body;  this  is  well  seen  in  the  palm  of  the  hands  and 
the  cells  of  the  internal  organs,  as  the  liver,  which  from  arduous 
labor,  die  and  are  cast  off.  Xow,  if  there  was  no  way  ia  which 
the  cells  could  be  replaced,  the  body  would  soon  become  shrunk- 
ened,  but  nature  provides  for  this,  and  by  a  process  of  regeneration 
new  cells  supply  the  waste.  In  early  life  the  cell  construction  is 
in  excess  of  the  waste,  and  the  body  consequently  grows;  in  adult 
life  the  processes  are  equal  and  the  size  of  the  body  remains  the 
same,  and  in  old  age  the  waste  exceeds  the  constructioQ  and  the 
body  atrophies.  Surgical  regeneration  consi<5ts  of  the  process  by 
which  defects  in  tissue  due  to  injury  are  repaired.  We  must  make 
a  sharp  distinction  between  surgical  regeneration  and  Inflamma- 
tion. It  was  formerly  thought  that  inflammation  was  necessary 
fcr  the  healing  of  a  wound;  this  is  absurd,  as  under  aseptic  treat- 
ment a  wouud  will  heal  without  inflammation.  Regeneration  is  a 
physiological  process;  Inflammation  is  a  pathological  process;  Sur- 
gical regeneration  is  a  building  up  or  healthy  process;  Inflamma- 
tion is  a  breaking  down  or  diseased  process  due  to  micro-organ- 
isms, while  surgical  if^generation  is  due  to  the  effort  of  nature  to 
resist  disease  and  to  overcome  injury,  and  the  effort  is  retarded  by 
inflammation. 

Pkocess  of  Eepaik  in  Wounds. — Remembering  the  explanation 
of  the  death  cells,  how  they  perform  their  work,  are  worn  out 
from  the  arduous  labor  and  are  cast  off,  it  will  be  w^ell  here  to 
study  how  these  cells  are  replaced.  In  every  organ  and  structure 
of  the  lody  there  are  found  what  are  called  '•''Fixed  tissue  cells,'''' 
these  cells  perform  no  work,  have  no  function,  but  simply  pro- 
liferates and  forms  new  cells  with  functions  according  to  whether 
they  were  develpf>ed  from  the  fixed  tissue  cells  of  the  Hypoblast, 
Mesoblast  or  Epiblast.  In  bone  we  have  cells  with  functions  called 
Sarcoblastic,  and  we  also  have  cells  without  functions  which  form 
new  bone  cells  and  are  called  Osteoblastic.  In  connective  tissue, 
which  binds  different  organs  togeth^sr,  we  also  find  cells  which  do 


PRINCIPLES    OF    SURGERY.  35 

not  bind,  bat  simply  proliferates  and  forms  new  cells,  these  fixed 
cells  are  called  Epiblastic.  Wounds  heal  by  the  proliferation  of 
these  fixed  cells.  At  one  time  it  was  thought  that  the  leucocytes, 
which  were  found  in  such  numbers  in  the  injured  part,  \\ere  con- 
verted into  new  tissue,  this  is  not  so,  the  leucocytes  have  no  power 
of  forming  new  tissue,  but  tbey  do  give  a  substance  "■Fihrin  fer- 
ment^''''  which  is  glutinous  and  holds  the  lips  of  the  vsound  to- 
gether (sutures  are  used  to  assist  the  leucocytes),  and  the  leuco- 
cytes, composed  as  they  are  of  proteid  material,  on  its  death  de- 
posits this  nutriment,  and  the  fixed  cells  use  it  as  food,  and  this  is 
the  only  way  they  assist  in  the  formation  of  new  cells. 

Granulation. — Granulation  is  the  process  by  v\hich  new  tissue 
cells  are  formed  in  a  wound  to  close  the  gap,  and  in  the  result  of 
the  proliferation  of  the  fised  tissue  cells  of  the  part.  If  a  cut  is 
made,  say  in  the  leg,  the  lips  of  the  wound  retracts  and  the  space 
is  filled  up  with  granulation,  which  is  a  prodigy  of  the  fixed  cells. 
Thisgraculation  tissue  will  be  formed  until  the  gap  is  entirely  filled 
up  and  there  is  nc  further  need  for  more. 

Yascularization. — This  is  a  process  by  which  new  blood  vessels 
are  formed  in  the  granulation  tissue.  When  a  wound  is  made  the 
fixed  cells  forms  a  coat  over  it  about  one-sixteenth  of  an  inch  thick, 
and  unless  this  coat  is  supplied  with  blood  the  growth  is  stopped, 
but  nature  provides  this  blood  supply.  The  new  vessels  are  formed 
from  the  nearest  blood  vessel  to  the  part.  The  first  change  noticed 
is  the  vessel  becomes  congested  and  four  or  five  wedge  shaped  pro- 
jections form  on  it,  the  base  of  the  wedge  turned  toward  the  vessel 
and  the  apex  toward  the  granulation  tissue.  The  wedge  increases 
in  size  and  begins  to  be  hollowed  out  at  its  base,  the  apex  of  one 
wedge  next  joins  the  apex  of  another  wedge  and  thus  capillary 
loops  are  formed  all  through  the  new  tissue.  These  blood  vessels 
are  not  permanent,  for  as  the  granulation  cells  become  converted 
into  more  mature  tissue  and  can  exist  without  these  vessels,  the 
tissues  contract  and  obliterates  them. 

Cicatrization  — Cicatrization  is  the  conversion  of  granulation 
cells  into  more  mature  tissue.  A  bone  cell  in  proliferating  begets 
a  bone  cell,  a  muscle  cell  begets  a  muscle  cell;  so  we  may  say 
that  all  cells  breed  true.  If  a  wound  be  in  a  muscle  the  granula- 
tion cells  are  a  prodigy  of  the  fixed  muscle  cells,  and  when  by 


36  PRINCIPLES    OF    SURGERY. 

cicatrization  they  become  mature  they  \\ill  have  all  the  character- 
istic properties  of  a  muscle  cell;  the  same  can  be  said  of  bone  epi- 
thelia  cells,  etc.  With  the  development  of  more  mature  tissue 
from  granulation  cells  by  cicatrization,  a  certain  amount  of  con- 
traction occurs,  due  to  the  fact  that  in  all  granulation  tissue  a  cer- 
tain amount  of  connective  tissue  is  formed,  this  contraction  forms 
the  cicatrix  and  serves  a  good  purpose  of  making  the  cicatrix 
smaller  and  by  obliterating  the  blood  vessels.  The  contraction, 
may  go  so  far  as  to  be  dangerous,  as  around  the  elbow  joint  it 
may  contract  to  such  a  degree  as  to  render  the  joint  useless  and 
deformed. 

Epidekmization. . — This  is  the  process  by  which  a  wound  is  cov- 
ered and  is  the  result  of  the  proliferation  of  the  fixed  cells  at  the 
margin  of  the^ound.  After  granulation  and  cicatrization  has 
taken  place,  these  cells  may  be  seen  coming  from  the  edge  of  the 
wound,  they  are  pale  and  look  like  the  skin  of  an  egg.  If  a  piece 
of  epithelium  is  left  in  the  wound,  proliferation  will  take  place  from 
it  also. 

Classification  of  Healing  Wounds. — Old  division: 

1.  Direct  or  immediate  union. 

2.  Plastic  inflammation. 

3.  Suppurative  inflammation. 

This  classification  was  given  by  John  Hunter.  He  thought 
when  the  surface  of  wounds  were  brought  together  they  immedi- 
ately healed;  he  also  thought  a  wound  healed  by  plastic  or  suppu- 
rative inflammation.  Under  our  present  kno\\ ledge  this  theory  is 
absurd,  as  we  know  inflammation  retards  healing. 

New  division: 

1.  Primary  intention  (aseptic  wound). 

2.  Secondary  intention  (infected  wound). 

This  classification  is  proven  by  observation.  All  wounds  heal 
by  regeneration.  A  wound  healing  without  inflammation  is  said 
to  heal  by  primary  intention  and  is  always  an  aseptic  wound.  A 
wound  healing  after  inflammation  is  said  to  heal  by  secondary  in- 
tention and  is  always  an  infected  wound. 


PRINCIPLES    OF    SURGERY.  37 


LECTURE  IX. 


EEGENERATION   OF   SPECIAL   TISSUES. 

Yegetative  Capacity  of  Tissue. — Tissues  differ  fron]  one 
another  in  their  rapidity  of  healing,  some  heal  quickly,  others 
slowly,  and  on  this  is  based  their  vegetative  capacity,  which 
means  the  power  the  tissue  has  of  healing.  Tissues  that  heal 
quickly  are  said  to  have  a  high  vegetative  capacity,  and  those  that 
heal  slowl}^  are  said  to  be  of  low  vegetative  capacity.  Muscles 
are  of  a  lower  vegetative  capacity  than  the  epidermis,  and  so  they 
differ  all  over  the  body.  The  vegetative  capacity  of  tissues  de- 
pends on  two  conditions:  1.  On  the  kind  of  cell  developed  from, 
tbe  lov^  er  the  cell  developed  from  the  higher  the  vegetative  capa- 
city, and  the  higher  the  cell  developed  from  the  lower  the  vegeta- 
tive capacity,  as,  for  illustration,  the  vegetative  capacity  of  a  rab- 
bit's tissues  are  higher  than  that  of  a  man,  because  the  rabbit  is 
of  a  lower  development,  and  a  wound  on  the  rabbit  will  heal 
quicker  than  on  a  man.  2.  Blood  supply  :  the  vegetative  capacity 
is  higher  the  more  bountiful  the  blood  supply,  and  tissaes  with  a 
poor  blood  supply  have  a  low  vegetative  capacity.  The  nervous 
tissue  is  the  most  highly  developed  tissue  in  man,  and  is  conse- 
quently of  low  vegetative  capacity;  epithelium  is  of  low  develop- 
ment and  of  a  high  vegetative  capacity. 

OoENEA. — When  a  cut  is  made  in  the  cornea  or  any  other  part, 
with  a  poor  blood  supply  and  of  a  low  vegetative  capacity,  it  is 
important  to  know  how  tbe  wound  will  heal  so  as  to  be  able  to  give 
a  prognosis.  The  cjrnea  is  composed  of  cells  placed  in  a  transpa- 
rent, homogeneous  matrix;  the  vegetative  capacity  is  low  on  ac- 
count of  its  being  a  tissue  of  high  development  and  with  a  poor 
blood  supply.  Eepair  is  due  to  the  proliferation  of  its  fixed  tissue 
cells.  If  examined  under  the  microscope  there  will  be  seen  cells 
M  hich  ditf er  from  the  regular  corneal  cells,  these  are  the  fixed 
tissue  cells,  and  when  the  cornea  is  injured  they  proliferate  and 
replace  the  injured  cells.  If  the  wound  be  aseptic  there  will  be 
formed  just  enough  cells  to  repair  the  injury;  cicatrization  takes 


38  PRINCIPLES    OF    SURGERY. 

place  aDcI  the  eye  returns  to  its  normal  appearance  with  the  sight 
uninjured,  but  if  the  pyogenic  germ  be  implanted,  which  causes 
the  proliferation  to  go  on  in  excess,  the  ne^  cells  will  never  be 
able  to  transmit  light. 

Treatment.  The  first  step  is  to  make  the  ti  ound  aseptic;  this 
is  hard  to  do  on  account  of  its  ccmmijnication  with  the  nose. 
Irrigate  the  Tvound,  wash  off  the  conjunctiva  and  eyelids,  flush 
out  the  lachrymal  duct  through  the  nose,  remove  all  blood  clots 
and  foreign  bodies  with  a  clean  needle,  press  the  lips  of  the  wound 
together  and  bandage  the  eye  up  tight  enough  to  hold  them  in 
apposition.     IsTever  suture  the  lips  together. 

Cartilage. — There  are  three  kinds  of  cartilage — Hyaline,  Fi- 
brous and  Yellow  elastic.  In  each  instance  they  are  made  up  of 
cartilage  cells  placed  in  a  homogeneous  matrix.  Cartilage,  although 
not  a  highly  developed  tissue,  is  of  a  low,  vegetative  capacity,  on 
account  of  its  very  poor  blood  supply.  The  injury  may  last  a  long 
time  on  account  of  its  low  vegetative  capacity,  but  it  has  fixed 
cells,  which  finally  proliferate  and  heals  the  wound.  Xew  blood 
vessels  are  formed  from  the  vessels  in  the  perichondrium. 

TreatJDent.  Render  the  part  aseptic,  immobilize  it  and  give 
nature  a  chance. 

Epidermis. — The  epidermis  consists  of  the  epiderma  and  the 
derma.  The  epiderma  is  divided  into  four  layers.  It  is  a  non- 
vascular tissue,  composed  of  striated  epithelia  cells,  but  the  rela- 
tion to  the  adjacent  vascular  tissue  is  so  intimate  that  it  may  be 
regarded  as  a  vascular  tissue  with  a  high  vegetative  capacity,  con- 
sequentl}''  it  heals  readily.  Repair  takes  place  by  the  proliferation 
of  the  fixed  tissue  cells  of  the  part,  and  is  entirely  from  the  margin 
of  the  wound,  as  epithelia  begets  epithelia  cells,  and  the  skin 
around  the  wound  is  the  nearest  from  which  proliferation  can  take 
place.  The  new  cells  are  pale,  resembling  the  skin  of  an  egg. 
The  tine  taken  to  cover  the  wounded  surface  depends  on  the  size 
of  the  wound;  if  the  surface  be  large,  the  time  may  be  indefinite, 
as  in  cancer  of  the  face  where  the  surface  is  large  it  necessarily 
takes  a  long  time  and  often  it  is  never  covered,  for  after  a  long 
time  the  process  of  proliferation  stops  on  account  of  the  cells  be- 
coimng  exhausted,  when  a  hard  callous  will  form  on  the  edge  of 
the  wound  and  all  signs  of  healing  disappears  and  you  then  have 


PRINCIPLES    OF    SURGERY.  39 

an  Ulcer  to  deal  with.  A  wound  with  a  sir  all  surface  is  soon  cov- 
ered. 

Treatment. — Up  to  a  fe\^  years  ago  a  wound  like  the  first  de- 
scribed above,  without  vitality,  was  a  bugbear  to  the  surgeon,  the 
treatment  was  to  give  nature  a  rest,  protect  the  wound  and  to 
build  up  the  patient's  general  healtn.  The  treatment  of  to  day  is 
different,  we  do  not  wait  for  nature,  but  force  the  wound  to  heal 
by  a  process  called  Skin  Grafting,  whicti  consists  of  taking  skin 
from  other  parts  of  the  body  and  implanting  it  on  the  wounded 
surface,  when  by  ]ts  proliferation  the  surface  is  covered.  "We 
have  two  methods  of  skin  grafting,  which  are  generally  accepted, 
Reverdia's  and  Thiersch's;  both  methods  are  in  general  use,  both 
have  their  advantages  and  advocates.  They  are  used  under  two 
different  circumstances,  when  a  wound  fails  to  heal  and  when  a 
wound  is  inflicted. 

E-evekdin's  Method. — The  wound  having  had  all  hemorrhage 
stopped  by  means  of  pressure,  is  flushed  off  with  normal  saline 
solution.  Then  the  skin  on  another  portion  of  the  body  or  from 
some  other  person  is  rendered  aseptic;  with  a  clean  needle  lift  up 
the  skin  and  with  a  sharp  sterile  scalpel  cut  off  numerous  small 
specks  of  skin  and  carry  then:  to  the  wound  by  means  of  a  needle, 
place  them  on  the  wound  about  one-third  of  an  inch  apart,  with  a 
knowledge  that  about  two-thirds  of  your  grafts  will  grow  and  pro- 
liferate and  so  complete  the  epidermization  of  the  part. 

Thieusch's  "Method. — This  operation  is  much  more  heroic.  In- 
stead of  taking  inflnitesimal  pieces,  he  tates  slips  about  three-quar- 
ters of  an  inch  wide  and  places  them  on  the  wound.  After  the 
wound  has  been  prepared,  the  skin  on  another  portion  of  the  body 
is  made  aseptic  and  slips  are  shaved  off  with  a  razor;  these  are  laid 
on  the  wound  side  by  side,  with  their  edges  touching  and  a  pro- 
tective dressing  is  applied.  A  wound  which  would  not  have  healed 
in  three  or  four  months  can  be  made  to  heal  by  this  operation  in 
two  weeks.  The  skin  of  a  friend  or  of  a  fresh  cadaver  can  be 
used.  Reverdin's  method  can  be  used  without  anaesthesia,  but  it 
is  best  to  administer  some  aniBsthetic  in  using  Thiersch's  method. 

Connective  Tissue.  —  This  tissue  has  an  abundant  supph'  of  blood 
and  is  of  a  high  vegetative  capacity.  It  embraces  both  white  and 
yellow  elastic  tissue.  It  heals  by  proliferation  of  its  fixed  tissue 
cells  and  needs  no  special  treatment. 


40  PRINCIPLES    OF    SURGERY. 

Muscles. — Muscles  are  of  two  kinds — Striped  and  Unstriped. 
The  striped  muscles  constitute  the  muscles  of  the  skeleton  and 
are  under  the  control  of  the  will.  Unstriped  constitute  the  muscles 
of  the  internal  organs,  as  the  stomach  and  intestines,  and  are  not 
under  the  control  of  the  will.  Unstriped  muscles  consist  of  fusi- 
form cells  containing  a  nucleus  and  nucleolus.  The  cells  are  im- 
bricated and  in  broad  sheets,  which  envelopes  such  organs  as  the 
stomach,  etc.  "When  injured,  regeneration  takes  place  by  prolifer- 
ation of  its  fixed  tissue  cells  by  Karyokinesis,  which  goes  on  very 
readily. 

Striped  muscles  are  much  more  common,  as  Biceps,  Triceps,  etc. 
They  are  invested  by  fascia  and  divided  into  t undies  by  the 
Perimysium  and  into  smaller  bundles  by  the  Endomysium  and  the 
fibres  are  invested  by  the  Sarcolemma.  Between  the  sarcclemraa 
and  the  fibre  at  various  intervals  you  find  the  fixed  tissue  cells, 
these  cells  when  the  muscle  is  injured  proliferates,  burst  through 
the  sarcolemma  and  then  they  divide  and  sub-divide  until  the  in- 
jury is  repaired. 

Treatment. — When  a  large  muscle  is  cut,  especially  if  it  is  cut 
transversely,  it  is  your  duty  to  suture  the  ends  together,  as  much  so 
as  it  is  your  duty  to  reduce  a  fractured  bone.  Unless  you  suture 
the  muscle  it  will  be  useless  to  the  patient.  If  the  ends  retract, 
and  it  is  difficult  to  get  them  together  or  even  to  reach  them,  don't 
hesitate  to  make  the  wound  larger.  After  getting  the  ends  relax 
the  muscle  by  position  (if  it  is  the  biceps  flex  the  forearm  on  the 
arm),  bring  the  ends  together  and  suture  them,  using  the  Mattress 
suture.     Suture  the  fascia  separately. 

Tendon. — Tendons  are  composed  of  white  fibrous  tissue.  They 
are  much  smaller  than  muscles,  but  a  great  deal  stronger;  in  fact, 
it  is  the  strongest  tissue  in  the  body.  One  end  of  a  tendon  is 
attached  to  bone,  the  other  end  to  muscle,  they  thus  make  loco- 
motion easy  and  economize  space.  Tendons  are  sometimes  rup- 
tured or  cut,  and  the  loss  of  their  continuity  means  the  loss  of  the 
use  of  the  muscle  it  is  attached  to,  unless  the  fixed  cells  proliferate 
and  fill  the  gap.  A  tendon  v/hen  cut,  should  be  invariably 
sutured,  and  when  called  to  a  case  and  on  arriving  fiud  the  wound 
has  closed,  don't  just  bind  the  part  up  and  leave,  but  find  out  the 
extent  of  the  injury,  and  if  any  tendons  are  cut  suture  them  to- 


PRINCIPLES    OF    SURGERY.  41 

gether  and  be  sure  you  get  the  right  ends  in  opposition;  use  the 
simple  suture.  Suppose  a  case  comes  to  you  after  being  injured  six 
months  and  tells  you  one  of  the  tendons  to  his  finger  has  been  cut 
and  has  not  grown  together,  don't  send  the  patient  away,  dissect 
down  on  the  tendon,  get  the  ends  and  splice  them  so  as  make  them 
long  enough;  sevei  the  tendon  half  way  through  about  one  inch 
from  each  end,  split  it  down  near  to  the  end  and  turn  end  to  end 
and  suture,  and  you  will  get  a  nice  result. 


LKCTURE  X. 


EEGEISTERATION    OF    SPEC^IAL    TISSUES.— CoNTmuED. 

Blood  V^essels.-  -This  terir  includes  all  thiee  types  of  blood  ves- 
sels, Arteries,  Yeias  and  Capillaries,  the  structure  of  each  has  been 
considered  before.  Blood  vessels  are  of  a  high  vegetative  capacity, 
nature  recognizing  the  necessity  for  their  rapid  repair  when  in- 
jured so  endowed  them.  When  a  blood  vessel  is  cut  the  tunica 
intima  and  tunica  media  firmly  adhere  to  each  other,  they  then 
retract  from  the  tunica  adventitia  and  their  edges  turn  inward. 
The  blood  passing  over  their  edges  coagulates  and  forms  a  throm- 
bus on  their  inner  side,  therebv  stopping  the  flow  of  blood.  The 
thrombus  thus  formed  is  a  temporary  affair,  as  it  is  soon  absorbed, 
but  before  it  is  absorbed  nature  heals  the  vessel  permanently  by 
the  proliferation  of  the  fixed  tissue  cells  of  the  tunica  media,  which 
are  called  Angio blast,  and  a  permanent  cicatrix  is  formed.  Up  to 
ten  or  fifteen  years  ago  the  process  was  not  understood;  it  was 
thought  it  was  caused  by  the  organization  of  the  thrombus,  but 
this  is  not  true,  the  lav^  of  regeneration  from  the  fixed  tissue  cells 
holds  good  here  as  in  any  portion  of  the  body.  The  older  surgeons 
had  the  complication  of  secondary  hemorrhage  to  deal  with,  they 
would  on  amputating  a  leg,  tie  the  arteries  and  put  the  patient  to 
bed,  thinking  he  was  all  right,  but  in  five  or  six  days  secondary 
hemorrhage  would  come  on,  due  to  the  wound  being  infected  from 


42  PRINCIPLES    OF    SURGERY. 

ufing  dirty  ligatures,  the  thrombus  would  disintegrate  and  the 
patient's  life  put  at  hazards.  Wounds  in  olden  times  were  always 
infected  and  never  healed  by  primary  intention.  "With  our  mod- 
ern aseptic  surgery  we  are  never  bothered  with  secondary  hemor- 
rhage, so  let  this  be  your  motto.  ^'' Be  clean.''' 

Treatment. — The  subject  of  hemorrhage  is  a  big  one,  and  can't 
be  treated  of  fully  here.  When  the  hemorrhage  is  slight,  control 
it  with  very  hot  solutions,  which  cause  coagulation,  or  by  pi  assure 
or  elevation,  but  when  a  large  artery  is  cut,  you  musl  ligate  it; 
ligate  both  ends,  even  if  it  is  only  tleediug  from  one,  for  when, 
reaction  comes  on  you  are  liable  to  have  hemorrhage  from  the  end 
which  did  not  bleed  wMiile  the  heart  w^as  depressed.  If  the  artery 
is  only  cut  half  in  two,  complete  the  division  and  tie  both  ends. 

Nerves. — 'The  nervous  system  is  divided  into  two  great  divisions. 
Central  and  Peripheral.  The  nervous  system  is  likened  unto  a  tele- 
graphic system ;  you  have  a  central  station  represented  by  the  brain 
and  spinal  cord,  and  the  wires  leading  from  the  central  station 
represent  the  peripheral  nerves.  The  central  system  is  very  com- 
plex, and  being  of  high  development,  it  is  of  low  vegetative 
capacity,  and,  therefore  when  injured,  it  heals  slowly.  The  peri- 
pheral nerves  are  of  a  high  vegetative  capacity.  They  are  com- 
posed of  the  fibre  enclosed  in  the  endoneurium,  the  fibres  are  in 
bundles  surrounded  by  the  perineurium  and  the  bundles  are 
grouped  together  and  surrounded  by  the  epineuriura.  The  nerve 
fibre  is  composed  of  the  axiscj^^linder  enclosed  in  the  axillemma, 
this  is  surrounded  by  the  white  substance  of  Schwann,  and  this  is 
surrouuded  by  the  neurilemma.  At  variable  intervals  alcng  the 
fibre,  there  are  seen  constrictions,  called  the  Nodes  of  Racvier,  and 
at  this  point  between  the  neurilemma  and  the  white  substance  of 
Schwann  we  find  the  fixed  tissue  cells  called  Neuroblast,  and  by 
their  proliferation  injuries  to  the  n-^rves  are  repaired. 

Treatment. — ^Cruickshank  was  the  first  experimenter  to  try  sutur- 
ing the  ends  of  divided  nerves  toojether,  but  he  did  not  succeed  on 
account  of  the  ignorance  existing  in  his  days  in  regard  to  asepsis. 
It  is  now  employed  successfully  in  every  day  practice,  and  you  had 
just  as  well  leave  the  ends  of  a  broken  bone  unapproxiraated  as  to 
leave  a  divided  nerve  unsutured.  Nerves,  when  immediately  cut, 
can  be  easily  sutured,  and  their  function  will  be  restored  in  forty- 


PKINCIPLES    OF    SURGERY.  43 

eight  hours.  Xever  use  the  regular  surgical  needle  with  sharp 
edges  in  suturing  a  nerve,  use  the  common  cambric  needle,  employ- 
ing an  aseptic  suture  of  catgut  or  silk.  The  operation  was  at  first 
thought  to  be  very  painful,  but  if  it  is  done  asepticallv,  it  does  not 
give  rise  to  much  pain.  If  you  find  it  necessary  suture  the  peri- 
neurial  sheath  with  a  separate  suture. 

Sometiioes  a  patient  will  come  to  you  and  say  he  has  lost  all 
sensation  in  one  of  his  limbs,  and  on  inquiry  you  find  out  that  in 
some  previous  operation  or  by  a  fractured  bone  the  nerve  has  been 
severed  and  has  not  grown  together.  What  will  you  do?  Do  this, 
perform  a  secondary  operation;  render  the  part  bloodless  by  using 
a  tourniquet,  make  the  limb,  your  hands  and  instruments  sterile, 
dissect  down  and  find  the  ends  of  the  nerve,  clip  oil  their  bulbous 
extremities  and  practice  either  of  these  methods:  ^^ Sutures  a  dis- 
tance^'"' in  this  the  sutures  form  a  scaffolding  for  the  new  cells,  the 
sutures  are  run  from  one  cut  end  of  the  nerve  to  the  other,  and 
the  new  cells  are,  as  it  were,  carried  across  on  a  bridge  from  one 
end  of  the  nerve  to  the  other  until  the  breach  in  its  continuity  is 
mended;  or  you  can  use  the  second  method,  take  a  chicken  bone 
tube,  saw  off  the  ends,  decalsify  it  and  make  aseptic,  put  the  ends 
of  the  nerve  in  the  tube  and  sew  up  the  wound;  the  hollow  bone 
causes  the  cells  to  proliferate  toward  the  breach  until  it  is  finally 
mended.     jSTerve  grafting  up  to  this  time  has  not  succeeded. 

BoxE. — Bone  forms  the  skeleton  or  framework  of  the  body,  it  is 
the  hardest  structure  in  the  body,  being  composed  of  both  animal 
and  mineral  matter.  Most  all  bones  are  hollow  internally  and 
coated  by  a  ncembrane  called  the  Endosteum.  Externally  they 
are  coated  by  a  membrane  called  the  Periosteum.  Bones  have 
canals  running  all  through  them  called  Ha  version  canals,  these 
canals  are  surrounded  by  spaces  called  Lacuna^,  which  commuQi- 
cate  with  each  other  and  the  Haversion  canals  by  minute  channels 
call-^d  Canaliculi.  In  the  periosteum,  endosteurr  and  lacunae  are 
round  cells  called  osteoblast,  which  are  put  there  to  repair  normal 
physiological  waste,  but  when  the  bone  is  injured  they  take  on 
greater  vitality  and  repair  the  injury  by  pouring  out  granulations 
called  Callus.  When  first  formed  the  callus  is  soft  and  elastic,  but 
after  cicatrization  occurs  the  soft  uncharacteristic  cells  become 
converted    into    hard   bone   cells.      More  callus  is  formed  than  is 


44  PRINCIPLES    OF    SURGERY. 

necessary  to  mend  the  breach,  this  will  be  understood  after  the 
process  is  described.  When  a  bone  is  broken  the  osteoblast  of  the 
periosteum  proliferates  and  forms  callus  on  the  outside,  this  is 
calkd  External  or  splint  callus;  the  osteoblast  of  the  endosteum 
proliferates  and  forms  callus  in  the  medullary  cavity,  which  is  called 
Internal  or  l-'in  callus,  and  the  osteoblast  of  the  lacunae  prolifer- 
ates and  forms  callus  between  the  divided  ends,  this  is  called  Inter- 
mediate or  Definitive  callus.  The  callus  in  each  place  is  thrown 
out  in  abundance,  the  external  callus  acting  as  a  splint,  the  inter- 
nal as  a  pin,  and  the  intermediate,  which  is  permanent,  heals  the 
breach.  The  internal  and  external  callus  after  performing  their 
purpose  is  absorbed. 

Sometimes  the  callus,  owing  to  some  constitutional  or  local 
trouble,  is  formed  in  excessive  amounts,  this  may  be  due  to  syphi- 
lis, tuberculosis  or  to  the  bone  not  being  immovably  nxed,  and 
when  it  occurs  the  seat  of  the  fracture  is  the  seat  of  a  tumor,  which 
feels  like  a  hard  lump.  The  treatment  of  the  above  should  be  the 
administration  of  antisyphilitic  remedies,  absolute  immobility  of 
the  bones  and  confine  the  patient  to  bed.  Again,  callus  may  be 
deficit  in  amount,  and  this  again  is  due  to  syphilis,  tuberculosis, 
old  age  and  insufficient  blood  supply.  When  the  bone  is  examined 
you  will  find  no  swelling  or  anything  to  show  that  healing  has  com- 
menced. The  treatment  should  be  directed  toward  building  up 
the  patient's  general  health;  irrigate  and  thus  stimulate  the  cells 
to  proliferate,  this  can  be  done  by  rubbing  the  ends  together.  If 
this  does  not  effect  a  union,  give  the  patient  an  anaesthetic,  render 
everything  aseptic,  open  the  limb  down  to  the  seat  of  the  fracture, 
saw  off  the  ends  of  the  bone,  drill  a  hole  in  each  end  and  fasten 
them  together  ^-ith  a  bone  nail.  The  most  satisfactory  operation 
is  the  Step  operation,  in  this  the  bone  is  sawed  like  a  step,  each 
end  having  a  shoulder  which  fits  quite  accurately,  it  is  then  held 
in  position  with  silver  wire. 

It  is  a  practical  fact  that  when  a  bone  is  removed  from  any  part 
of  the  body  that  if  the  periosteum  is  left  the  bone  will  regenerate 
from  it.  A  case  is  reported  where  the  entire  collar  bone  was  re- 
moved and  the  periosteum  left,  whereas  the  entire  bone  was  restored 
in  two  or  three  months.  Theoretically  it  is  claimed  that  unless  a 
small  piece  of  bone  is  left  the  bone  will  not  regenerate,  but  it  will, 


PRINCIPLES    OP   SURGERY.  45 

provided  the  m  ound  be  aseptic,  the  periosteum  sewed  up  and  slightly 
irrigated. 

Treatment  of  Fractures. — There  are  two  indications  when  a 
fracture  occurs,  reduce  the  fracture  and  keep  the  fragments  in 
apposition  by  some  mechanical  appliance. 


LKCTURE  XI. 


suppuratio:n^. 

SuppDRATioN  may  be  defined  as  the  process  by  which  the  pro- 
ducts of  inflammation  are  converted  into  pus.  For  many  years 
the  phenomena  was  not  understood.  About  thirty  years  ago  an 
experimenter,  vchil^  exaiDining  pus,  sawr  between  and  in  the  pus 
corpuscles  certain  minute  round  bodies,  but  was  unable  to  explain 
anything  about  them.  Koch,  working  on  the  same  line,  said  he 
believed  they  were  micro-organisms,  and  by  further  investigation 
he  proved  that  they  were  germs  and  not  products  of  inflammation. 
It  is  now  generally  accepted  that  suppuration  is  due  to  a  specific 
germ,  and  moreover,  it  can  be  proven  by  fulfilling  the  laws  of 
Koch.  These  bacteria  always  accompa.ny  suppuration;  they  can 
be  cultivated;  the  cultivated  germs  if  injeciecl  into  an  animal  will 
cause  suppuration;  they  will  be  found  in  the  pus  from  this  animal. 
It  can  also  be  proven  clinically  as  well  as  bacieriologically  that 
it  is  due  to  a  germ;  if  you  make  a  wound  clean,  it  "will  heal  with- 
out suppuration,  whereas  in  a  dirty  wound  you  invariably  have 
suppuration.  After  a  wound  has  suppurated  by  heroic  treatment 
with  strong  antiseptics,  you  can  kill  the  germs  and  suppuration  at 
once  ceases. 

Causes. — The  causes  of  suppuration  may  be  divided  into  predis- 
posing and  essential. 

1.  Predisposing. — Diminished  vitality  of  the  tissues.  If  any 
part  of  the  body  is  congested  or  inflamed,  or  for  any  reason  is  de- 


46  PRINCIPLES    OF    SURGERY. 

pressed,  you  have  a  weak  poiat  where  the  germ  may  localize  and 
cause  suppuratioD. 

Anatomical  structure  of  the  part. — Some  structures  are  more 
liable  to  suppuration  than  others;  this  is  explained  by  the  fact  that 
some  organs,  for  instance  the  liver,  has  terminal  distribution  of 
arteries,  these  arteries  end  bluntly  and  do  not  anastomose  as  in 
other  parts,  and  uonsequentl}^  when  they  become  plugged  they  have 
no  means  of  establishing  a  collateral  circulation,  and  as  a  result, 
it  is  more  liable  to  suppuration  than  parts  where  the  vessels  anas- 
tomose freely. 

Condition  of  the  blood. — If  from  any  debilitating  diseases,  as 
anemia  or  diabetes,  the  character  of  the  blood  is  below  par,  sup- 
puration is  liable  to  occur.  This  is  well  seen  in  Diabetes,  when 
sugar  circulates  freely  in  the  blood,  with  the  result  of  superficial 
abscesses  all  over  the  body. 

Kumber  of  germs  introduced. — An  investigator  has  recently 
made  a  solution  of  the  germs  of  suppuration,  in  which  he  knew 
how  many  germs  there  were  to  the  drop  of  the  solution,  and  by 
injecting  this  solution  into  animals  he  found  out  how  many  of  the 
germs  it  took  to  produce  suppuration.  Each  drop  of  the  solution 
represented  eighteen  million  germs.  Into  one  animal  he  injected 
one  drop,  another  two  and  another  three,  but  in  none  of  the  ani- 
mals did  suppuration  occur,  but  when  he  injected  them  in  quan- 
tities amounting  to  one  billion  germs  suppuration  occurred.  The 
action  of  the  white  corpuscles  or  phagocytes  explains  this.  The 
phagocytes  were  able  to  cope  with  from  eighteen  to  thirty-six  mil- 
lions of  the  germs,  and  prevented  their  producing  suppuration, 
but  when  a  billion  were  injected  they  overcame  the  phagocytes  and 
produced  their  effect. 

2.  Essential  cause. — The  essential  cause  is  the  microbe  of  suppu- 
ration, of  which  we  recognize  about  fifteen  varieties. 

StajjhyloGOCcus pyogenes  aureus. —  As  the  name  indicates  this  is  a 
round  cell,  about  1  MM.  in  diameter,  grows  in  agar  agar,  blood 
serum  and  glycerin,  multiplies  by  direct  division  and  forms  bunches: 
Its  peculiarity  is  that  when  growing  it  imparts  an  orange  color  to 
the  fluids. 

Staphylococcus  p}yogenes  alhus. — This  is  also  a  round  cell,  and  is 
only  differentiated  from  the  above  by  its  imparting  a  white  ap- 
TDearance  to  the  media. 


PRINCIPLES    OF    SURGERY.  47 

Staphylococcus  pyogenes  citreus. — This  germ  is  identical  in  size 
and  shape  vsith  the  above  and  grows  in  the  same  media.  Its  dis- 
tinctive feature  is  that  it  imparts  a  very  dark  orange  color  to  the 
media  in  which  it  is  cultivated. 

Staphylococcus  cereus  albus. — This  is  a  slightly  smaller  cocci  than 
the  preceding,  but  otherwise  is  identical.  When  growing  it  forms 
round,  waxy  white  bodies,  sometimes  spoken  of  as  its  eggs. 

Staphylococcus  cereus  flavus. — This  cocci  is  identical  with  the 
above,  with  the  exception  that  the  bodies  formed  are  round,  waxy 
and  yellov7. 

Staphylococcus  fiavescens . — This  cocci  has  no  distinctive  feature, 
it  stands  midway  between  the  staphylococcus  cereus  albus  and 
flavus.  It  is  said  to  cause  stitch  bole  suppuration.  It  is  found 
principally  on  ^he  fingers.  It  multiplies  very  rapidly  and  forms 
bunches. 

Micrococcus  pyogenes  tenius. — This  germ  has  only  recently  been 
discovered.  It  is  found  in  abscesses  which  do  not  cause  any 
marked  constitutional  disturbances. 

Streptococcus  pyogenes. — ^This  is  the  most  important  specie  of  all 
the  germs  of  suppuration.  It  is  a  round  cocci,  mutiplies  by  fission 
and  forms  chains,  it  multiplies  slowly  at  the  ordinary  temperatures, 
but  very  rapidly  above  these  temperatures.  It  imparts  a  bro^Yn 
hue  to  the  media. 

Bacillus  pyogenes  fetidus. — This  is  a  rod  shaped  germ  with  round 
ends,  possessing  two  nuclei.  It  imparts  a  stinking  odor  to  the 
media.  It  is  to  this  bacillus  that  the  stink  which  is  characteristic 
of  abscesses  in  the  vagina  is  due. 

Bacillus  p)yocyaneus. — This  is  a  rod-shaped  germ  with  rounded 
ends  with  but  one  nuclei.  It  is  charactrized  by  imparting  a  dark 
blue  color  to  the  media.  The  blue  granulations  of  an  infected 
wound  is  due  to  this  bacillus. 

Micrococcus  Gonorrhoea.  — This  is  a  round  cocci  usually  found  in 
pairs  forming  a  Diplococci.  It  is  found  chiefly  on  mucus  mem- 
branes. 

Bacillus  Coli  Communis. — This  is  a  rod-shaped  germ  with  blunt 
ends  possessing  one  nuclei.  It  grows  in  all  media,  but  does  not 
liquify  it.  These  bacilli  inhabit  the  intestines,  and  are  supposed 
to  assist  digestion,  but  if   any  lesion  occurs  in  the  intestines  and 


48  PRINCIPLES    OF    SURGERY. 

they  get  into  the  peritoneal  canity  they  will  produce  peritonitis. 
They  are  harmless  "while  in  the  intestinal  canal.  They  are  said  to 
be  the  cause  of  appendicitis,  the  appendix  becomes  predisposed, 
owing  to  defective  blood  supply,  the  bacilli  infects  it,  causing  sup- 
purative appendicitis. 

In  the  practice  of  surgery  you  \^  ill  find  that  suppuration  behaves 
differently  on  different  occasions,  sometimes,  as  in  an  abscess,  it  is 
localized  and  on  opening  the  abscess  the  suppuration  ceases,  again 
it  has  no  tendency  to  localize,  but  grows  ^;^orse.  This  difference 
is  due  to  the  peculiar  character  cf  the  germ  causing  the  suppura- 
tion. All  the  staphylococci  cause  localized  suppuration,  while  the 
streptococci  produce  diffuse  suppuration.  Eecently  there  has  been 
claimed  by  some  scientist  and  enemies  of  bacteriology,  that  sup- 
puration can  be  produced  without  the  pyogenic  germ ;  one  of  them 
took  a  glass  tube,  sterilized  it  and  inserted  into  it  some  sterilized 
croton  oil  and  then  sewed  it  in  his  arm,  he  claimed  that  suppura- 
tion was  produced.  It  is  true,  he  produced  something  like  pus, 
but  it  was  not  pus,  it  was  a  travesty  and  was  a  puruloid  and  not  a 
purulent  material.  Clinically  all  pus  is  produced  by  a  specific 
germ. 

Pus. — Pus  is  the  by-product  of  suppurative  inflammation.  It 
is  a  thick,  milky,  cream-like  fluid,  having  little  odor,  slightly  alka- 
line in  reaction,  specific  gravity  1030.  It  is  composed  of  pus 
serum  and  pus  corpuscles.  Pus  serum  consists  of  the  top  layer  of 
pus  after  it  stands  awhile.  It  is  a  clear,  transparent,  greenish 
yellow  fluid,  alkaline  in  reaction  and  resembles  and  is  almost  iden- 
tical in  chemical  composition  with  liquor  sanguinis.  Pus  corpus- 
cles form  the  solid  element.  They  are  simply  dead  leucocytes  and 
embryonal  cells.  They  vary  in  size  according  to  their  source, 
those  formed  from  the  leucocytes  are  the  size  of  the  leucocytes  and 
those  from  the  embryonal  cells  are  the  size  of  the  embryonal  cells. 
They  are  usually  round,  but  are  sometimes  very  fantastic,  this  is 
caused  by  the  leucocytes  in  death's  agoay  throwing  out  pseudo- 
podia  iu  vain  attenptsto  protect  itself,  rigor  mortis  coming  on 
and  catching  it  in  this  shape.  The  appearance  of  their  protoplasm 
is  granular;  an  ordinary  leucocytes  or  embryonal  cell  is  clear  and 
transparent,  but  on  their  death  putrefaction  sets  in  and  gives  them 
a  granular  appearance.     The  leucocytes  and  embryonal  cells  have 


PRINCIPLES    OF    SURGERY.  49 

only  one  nuclei,  pus  corpuscles  have  about  fifteen,  and  it  is  on  this 
accouDt  that  some  observers  claim  thera  to  be  living  cells,  and  the 
great  number  of  nuclei  are  due  to  the  division  of  their  original 
nucleus,  but  it  has  been  proven  that  they  are  not  a  result  of  repro- 
duction, but  of  disintegration,  and  so  not  an  evidence  of  construc- 
tion, but  of  destruction.  Acetic  acid  added  to  pus  corpuscles  causes 
them  to  become  clear  and  transparent;  water  causes  them  to  swell; 
liquor  potassae  at  once  destroys  them  by  converting  them  into  a 
gelatinous  mass. 

Clinical  Yarieties. — 1.  Laudible  pus. — This  means  a  good  or 
healthy  pus,  but  the  idea  of  saying  any  pus  is  good  or  healthy  is 
absurd;  but  the  name  has  been  in  use  so  long  that  it  is  hard  to 
discard  it.  It  means  the  best  pus  out  of  a  bad  assortment.  It  is 
thick,  creamy,  white  pus,  without  odor,  not  irritating  and  soon 
ceases,  leaving  a  healthy  gram:  lation. 

2.  Sanious pus.  —This  means  pus  stained  with  blood.  It  is  thin, 
acrid,  irritating  and  of  a  dark  red  color,  and  indicates  serious  conse- 
quences. 

3.  Fetid  pus. — This  means  stinking  pus.  It  is  commonly  found 
in  abscesses  near  the  rectum  and  in  the  va2,ina. 

4-  Chromatic  pus. — This  means  a  brilliantly  colored  pus,  as  the 
dark  blue  pus  produced  by  the  bacillus  pyocyaneus.  We  also  some- 
times see  dark  red  pus,  but  the  bacillus  which  ])roduces  it  has  not 
been  named. 

5.  Serous  pus. — This  means  pus  mixed  with  serum.  It  is  gene- 
rally found  near  serous  cavities. 

6.  Mucous  or  Muco-purulent  pus. — This  means  pus  mixed  with 
mucous.  In  a  bad  cold  you  see  mucous  flowing  from  the  nose, 
and  if  this  goes  on  to  a  catarrhal  condition  the  mucous  becomes 
mixed  with  pus. 

7.  Inspissated  pus. — Sometimes  in  splitting  open  an  old  abscess 
we  find  a  caseous  mass,  this  is  called  inspissated  pus.  It  is  caused 
by  the  serum  of  the  pus  being  absorbed,  leaving  the  pus  corpuscles 
behind,  which  forms  a  dry,  cheesy  mass. 


50  PRINCIPLES    OF    SURGERY. 


LECTURE   XII. 


CLINICAL    FORMS    OF   SUPPURATION 

In  accordance  to  the  time  taken  to  convert  the  products  of  in- 
flammation into  pus,  suppuration  is  divided  into  Acute,  sub-acute 
and  Chronic  suppuration.  These  terms  do  not  mean  that  there 
are  different  kinds  of  suppuration,  but  are  simply  used  to  designate 
the  intensity  of  the  process. 

Acute  suppuration  is  caused  bj^  a  germ  of  great  virnlency  and 
in  large  numbers.  The  symptoms  come  on  rapidly  and  reach  their 
height  in  two  or  three  days  and  then  subside.  In  this  form  all 
the  pus  corpuscles  are  derived  from  the  leucocytes,  for  the  process 
is  so  rapid  that  not  enough  time  is  given  for  the  embryonal  cells  to 
proliferate.     The  symptoms  are  pain,  heat,  redness  and  sw^elling. 

Sub- acute  suppuration  differs  from  the  preceding  only  in  not 
being  as  int^'nse,  it  is  produced  by  a  germ  of  less  virulency  and 
not  in  such  numbers..  The  symptoms  develop  slowly  and  last  for 
a  longer  time.  The  source  of  the  pus  corpuscles  are  from  both  the 
leucocytes  and  embryonal  cells,  as  in  this  form  time  is  given  for 
the  embryonal  cells  to  proliferate.  The  symptoms  are  the  same 
as  in  the  acute  form,  but  are  not  as  intense,  especially  the  pain. 

Chronic  suppuration  is  produced  by  an  exceedingly  attenuated 
germ,  and  these  are  only  in  small  numbers.  The  symptoms  are 
the  same  as  in  the  other  forms,  but  they  develop  more  slowly,  last 
longer  aud  are  not  so  intense.  The  pus  corpuscles  are  exclu- 
sively of  embryonal  cells,  as  the  development  is  so  slow  that  the 
stigmata  in  the  \essels  heal  and  do  not  allow  the  escape  of  the 
leucocytes  and  those  escaped  in  the  earlj'-  stage  are  absorbed. 

Abscess.  — An  abscess  may  be  defined  as  a  circumscribed  collec- 
tion of  pus  in  tissue.  A  collection  of  pus  in  a  preformed  sjjace  is 
not  an  abscess,  but  a  purulent  infiltration,  as  pus  in  the  fallopian 
tube,  peritoneal  and  thoracic  cavity,  in  these  cases  Pyo  is  added  to 
the  name  of  the  anatomical  cavity  as  Pyothorax,  etc.  We  have 
two  varieties  of  abscesses — Acute  and  Chronic;  this  does  not  mean 
that  they  differ  in  kind,  but  in  degree  and  intensity.     The  causes 


PRINCIPLES    OF    SURGERY,  51 

which  may  produce  an  abscess  are  numerous,  but  only  two  will  be 
considered,  predisposing  and  essential.  The  predisposing  cause  is 
anything  which  lessens  the  vitality  of  the  tissues.  The  essential 
cause  is  the  germ  of  suppuration,  usually  of  the  staphylococcus 
variety. 

Pathology. — This  germ  enters  through  an  '•'•Infection  Atrium^'''' 
penetrate  the  tissues  (usually  the  cellular  tissue),  there  rapidly  iu- 
ciease  in  number,  and  after  forming  quite  an  army,  attack  the 
tissue,  producing  inflammation.  They  first  attack  the  capillaries 
producing  hyperaeraia,  followed  by  transudation  and  exudation; 
soon  necrosis  sets  in,  which  is  due  to  the  evil  influence  of  the  grerms 
and  their  toxins,  and  to  starvation  of  the  tissues,  from  the  blood 
supply  being  cut  off  by  pressure.  After  the  death  of  the  tissues, 
liquif action  takes  place.  This  commences  in  the  center  and 
rapidly  progresses,  until  a  point  is  reached  where  nature  has  made 
preparations  to  protect  itself,  ifsature  does  this  by  the  cells  at  the 
margin  of  the  diseased  tissue,  proliferating  and  building  a  wall  of 
defence.  As  soon  as  the  germs  rind  they  can't  invade  the  tissue 
further  they  turn  their  attention  entirely  to  the  dead  tissue,  pep- 
tonizing it,  with  the  result  that  we  have  a  bag  full  of  fluid  pus. 
After  while  nature  congratulating  herself  on  having  successfully 
repulsed  the  enemy,  determines  she  will  get  them  entirely  off  of 
her  domains;  this  is  accomplished  by  a  process  called  '•'■pointing.''' 
The  pus  is  gradually  forced  to  the  surface  and  by  pressure  on  the 
skin  or  mucous  membrane  a  dark  spot  appears,  which  finally  breaks 
down  and  a  sinus  is  opened  through  which  the  pus  escapes. 

Acute  Abscess.—  The  acute  or  hot  abscess  usually  developes  in 
the  connective  tissue  beneath  the  skin.  The  causes  are,  as  before 
stated,  predisposing  (traumatism  or  debility)  and  essential,  which 
is  the  germ  of  suppuration. 

Symptoms. — The  constitutional  symptoms  are  chills,  fever,  ano- 
rexia and  nausea,  which  are  due  to  the  absorption  of  the  toxins. 
The  local  symptoms  are  heat,  redness,  swelling,  pain  and  fluctua- 
tion. When  an  abscess  is  developing,  the  pain  is  in  accordance  to 
the  number  of  nerves  and  the  elasticity  of  the  part.  The  swelling 
is  due  to  the  hyperaemia  of  the  vessels,  and  to  their  pouring  out 
exudations  and  transudations.  Heat  and  redness  is  localized  and  due 
to  the  increased   amount  of   blood  to  the  part.     After  the  above 


52  PRIXCIPLES    OF    SURGERY. 

symptoms,  on  careful  palpation,  you  can  detect  fluctuation,  which 
shows  pus  has  formed.  The  mode  of  obtaining  fluctuation  is  to 
place  one  finger  on  each  side  the  sw  elling,  and  by  producing  un- 
equal pressure,  first  with  one  finger  then  the  other,  a  wave  of  fluid 
is  set  up  which  can  be  readily  felt.  The  swelling  will  now  be 
noticed  to  become  cone  shaped,  the  surface  yellow  and  unless  the 
abscess  is  incised  ulceration  tates  place  from  pressure  and  the  pus 
escapes. 

Diagnosis. — This  is  usually  simple,  being  made  from  the  symp- 
tom of  inflammation  and  fluctuation.  But  occasionally  there  is 
difficulty  in  telling  if  it  is  an  abscess  or  an  aneurism,  and  the  two 
may  co-exist,  or  it  may  be  mistaken  for  a  rapidly  growing  tumor. 
The  use  of  the  aspirator  in  these  cases  clears  up  the  diagnosis.  An 
aspirator  is  simply  a  hollow  needle  fitted  on  to  a  syringe.  To  use 
the  aspirator,  render  the  part  aseptic,  sterilize  the  needle  by  pass- 
ing it  through  a  flame,  and  insert  it  under  the  skin  obliquely  for  a 
half  an  inch  before  entering  the  cavity,  by  this  means  a  valve  is 
formed,  \^hich,  on  withdrawing  the  needle,  prevents  the  escape  of 
the  contents  of  the  ti.mor.  After  the  needle  enters  the  cavity, 
y[  hich  is  recognized  by  the  lack  of  resistance,  withdraw  the  piston, 
and  if  it  is  an  abscess  you  will  get  pus  in  the  barrel  of  the  syringe, 
if  an  aneurism  you  get  blood,  and  if  a  tumor  you  will  get  a  certain 
amount  of  serum  and  epithelia  cells  and  by  esamining  these  under 
the  microscope  you  can  tell  the  kind  of  tumor  you  have  to  deal 
with. 

Treatment. — The  old  treatment  consisted  in  applying  a  poultice 
to  the  abscess  until  it  came  to  a  head  or  pointed,  and  then  it  was 
incised,  but  let  me  caution  you,  never  use  a  poultice,  it  has  two 
good  qualities,  noisture  and  heat,  which  can  be  obtained  by  im- 
mersing a  piece  of  cotton  in  a  hot  antiseptic  solution,  applying  it 
and  covering  with  oil  silk,  which  will  hold  the  heat  for  hours  and 
in  this  manner  you  get  all  the  good  qualities  of  a  poultice  and  do 
away  with  its  disadvantages,  the  chief  of  v^hich  is  the  extreme 
liability  to  infection.  When  you  are  certain  there  is  pus  in  an 
abscess  or  boil,  don't  wait  for  poultices  or  hot  fomentations  to  bring 
it  near  the  surface,  but  cut  down  with  a  free  incision,  irrigate 
the  cavity  and  drain.  In  cutting  down  into  a  deeply  seated  ab- 
scess,  you   must  know    the  anatomy  of   the  part,  and  if  there  be 


PRINCIPLES    OF    SURGERY.  53 

large  blood  vessels  or  nerves  interposed,  as  in  an  abscess  of  the 
deep  tissues  of  the  neck,  don't  jab  your  knife  down  into  the  cavity, 
but  practice  this  method.  After  rendering  the  part  aseptic  and 
your  hands  and  instruments  sterile,  make  a  small  incision  through 
the  sl^in,  then  with  a  pair  of  artery  forceps  bore  your  way  through 
the  tissues  down  into  the  cavity,  which,  when  reached,  can  be  told 
by  the  lack  of  resistance;  now  open  the  forceps  and  thus  dilate  the 
sinus  you  have  made;  if  the  abscess  be  very  large  continue  your 
boring  into  the  opposite  wall  from  the  inside  until  the  forceps  show 
beneath  the  skin,  then  slightly  open  them  and  cut  the  skin  be- 
tween the  blades.  Irrigate  the  cavity  with  antiseptic  solutions, 
give  free  drainage  and  put  on  a  protective  dressing. 

Chronic  or  Cold  Abscess.  —These  abscesses  are  usually  tuber- 
cular in  origin,  the  person  having  previously  had  tuberculosis  of 
the  bones  or  some  other  tissue  and  the  bacilli  floating  around  gets 
into  the  embryonal  cells,  causing  a  cold  abscess.  Their  usual  seat 
is  on  the  back,  thighs  or  knees. 

Causes. — The  predisposing  cause  is  the  existence  of  tuberculosis 
in  some  of  the  tissues,  and  the  essential  cause  is  the  introduction  of 
the  pus  germ  in  these  tubercular  areas. 

Symptoms. — The  local  symptoms  are  vague  and  uncertain,  there 
is  no  pain,  redness  or  heat;  the  only  symptom  is  swelling,  which 
developes  exceedinly  slow  and  gives  fluctuation  on  palpation. 
The  constitutional  symptoms  are  those  of  tuberculosis,  a  rise  of 
temperature  in  the  evening,  diarrhoea,  nighl  sweats  and  general 
emaciation. 

Diagnosis.—  The  diagnosis  is  based  on  the  history;  inquire  into 
the  family  history,  look  at  the  spine  for  Pott's  disease,  at  the  hip 
for  Coxalgia,  and  lastly  obtain  some  of  the  fluid  with  an  aspirator, 
examine  it  under  the  microscope  for  the  Tubercle  bacillus. 

Treatment.— There  are  two  principal  methods  of  treatment — 
Incision  and  Aspiration.  When  the  primary  focus  is  accessible,  it 
should  be  treated  with  a  free  sweeping  incision,  dissect  out  the 
capsule,  irrigate  with  heroic  antiseptics,  such  as  bi-chloride  of  mer- 
cury, and  close  the  wound.  But  if  the  abscess  is  so  situated  that 
it  can't  be  readily  gotten  at,  practice  the  second  method:  Take  a 
large  trocar,  sterilize  it  by  passing  it  through  a  flame  and  plunge 
it  into  the  cavity,  withdraw  the  blade  and  ailow  the  fluid  to  run 


54  PRINCIPLES    OF    SURGERY, 

out  through  the  canula,  irrigate  the  cavity  through  the  canula 
"U'ith  strong  antiseptic  solutions  until  the  solutions  return  un- 
colored  "with  pus,  then  inject  into  the  cavity  5ss  to  ^i  of  a  ten  per 
cent,  solution  of  Iodoform  in  glycerine,  withdraw  the  canula  and 
seal  the  opening  with  a  piece  of  adhesive  plaster  to  prevent  the 
escape  of  the  Iodoform;  repeat  this  every  two  weeks.  This  treat- 
ment IS  based  on  the  fact  that  by  aspiration  you  eliminate  so  many 
of  the  bacilli,  and  b}''  using  antiseptics  you  kill  the  germs  present 
and  the  iodoform  prevents  their  further  growth. 


LECTURE  XIII. 


CLINICAL    FORMS    OF    SUPPURATION.— Continued. 

Phlegmonous  Inflammation  with  Suppuration. — This  subject 
is  contrasted  with  abscesses,  an  abscess  being  a  circumscribed  col- 
lection of  pus,  while  phlegmonous  inflammation  is  characterized  by 
its  tendency  to  spread  and  is  a  much  more  serious  condition.  It 
may  be  defined  as  a  rapidly  spreading  inflammation,  accompanied 
by  suppuration,  usually  involving  the  connective  tissue  of  the  ex- 
tremities and  showing  no  tendency  to  localize. 

Cause, — The  essential  cause  is  the  microbe  of  suppuration.  The 
microbes  which  cause  suppuration  are  about  fifteen  in  number,  of 
these  the  Staphylococcus  are  found  in  abscesses  and  the  streptococ- 
cus in  phlegmonous  inflammation.  The  predisposing  causes  are 
injuries  to  the  connective  tissue  of  the  extremities,  as  in  crushing 
wounds  in  railroad  accidents  and  in  compound  fractures. 

Symptoms.  —The  sViiiptoms  generally  come  on  in  about  four  days 
after  the  injury,  commencing  with  a  chill,  followed  by  a  rapid 
rise  of  temperature,  which  may  reach  104  to  105  degrees  F.,  rapid 
bounding  pulse,  full  respiration,  skin  hot  and  dry^  the  wound  angry 
looking,  a  bloody,  serous  discharge  comes  from  it.  the  tissues  boggy 
and  pitting  on  pressure,  the  swelling  extends  up  and  down  the  limb 
and   the   exudations   are  rapidly  converted    into  pus.     The    pro- 


PRINCIPLES    OF    SURGERY.  00 

cess  extends  along  the  muscles  and  nerves,  over  the  arteries  and 
Teins,  and  when  an  incision  is  made  into  the  tissues  they  look  as  if 
they  had  been  dissected  out  with  a  knife. 

Treatment.-- -The  treatment  to  save  life  must  be  heroic.  Thepus 
is  ground  down  and  infiltrated  into  every  part  of  the  tissues,  and 
the  operation  must,  be  looked  on  as  a  major  operation.  Give  the 
patient  an  ana3Sthetic,  make  the  site  of  the  operation  clean  by  using 
hot  water  and  green  soap,  alcohol  and  bi-chloride;  make  your  hands 
and  instruments  sterile,  and  with  a  free  incision  expose  all  the  tis- 
sues involved,  follow^  out  the  course  of  the  pus  minutely,  sponge 
the  w^ound,  irrio^ate  with  boracic  or  salicvlic  acid  solution,  give 
free  drainage,  apply  plenty  of  absorbing  cotton,  bandage  up  the 
part  and  put  the  patient  to  bed.  Watch  the  patient,  and  if  in  three 
or  four  days  you  lind  him  with  fever,  remove  the  dressing  and 
drainage  tubes,  lay  the  limb  out  on  the  bed  o^  er  a  piece  of  rubber 
and  resort  to  continual  irrigation.  This  can  be  done  by  putting  a 
fountain  syringe  on  the  bed  post,  and  let  some  feeble  antiseptic 
solution  flow  over  the  wound.  In  this  way  you  wesh  off  the  pus 
as  fast  as  it  is  formed  and  thus  its  absorption  is  prevented.  The 
current  of  water  can  be  nicely  regulated  with  a  clothes  pin.  By 
feeble  antiseptic  solutions  is  noeant  non-poisonous  solutions;  our 
best  antiseptics,  bi-chloride  of  mercury  and  carbolic  acid,  are  poison- 
ous and  can't  be  used  on  such  large  surfaces,  and  consequently  we 
resort  to  feebler  antiseptics,  such  as  chloral  hydrate,  boracic  and 
salicylic  acid,  acetate  of  aluminum,  etc.  A  splendid  non-poison- 
ous antiseptic  solution  can  be  made  by  the  addition  of  Tinct.  Iodine 
to  water  until  it  assumes  a  cherry  wine  color.  In  extreme  cases, 
where  the  above  means  have  been  resorted  to  and  failed,  amputa- 
tion must  be  resorted  to  in  order  to  save  life.  In  amputating 
always  operate  high  enough  up  above  the  infected  tissue  to  secure 
a  healthy  flap.  The  operation  under  these  conditions  is  extremely 
grave. 

Paronychia. — Paronychia,  whitlow  or  felon  are  svonymous 
terms  applied  to  suppurative  inflammation  of  the  Angers.  It  may 
form  under  the  skin,  tendon  or  periosteum. 

Cause. — The  cause  is  the  microbe  of  suppuration,  it  never  occurs 
without  this  microbe,  and  if  the  history  of  the  case  be  inquired 
into,  it  will  be  found  that  the  skin  has  been  broken  by  a  splinter 


56  PRINCIPLES    OF    SURGERY. 

or  other  means,  thus  giving  entrance  to  the  germ.  It  is  seen  in 
carpenters,  cooks  and  surgeons  very  frequently. 

Symptoms. — There  is  throbbing  pain  and  the  finger  is  swollen, 
red,  hot  and  congested. 

Treatment. — The  treatment  usually  folloAved,  consist  of  paint- 
ing the  finger  with  Iodine,  or  the  application  of  a  poultice,  and 
after  the  doctor  finds  out  the  finger  is  getting  worse,  he  jabs  a 
knife  into  it,  and  allows  the  patient  to  do  the  cutting  by  jumping. 
J^ever  be  guilty  of  treating  a  case  like  this.  The  first  treatment 
is  the  prophylactic;  care  for  the  nails  by  keeping  the  skin  pushed 
well  back  off  them,  keeps  the  fingers  free  from  hang  nails  and  use 
antiseptics  from  time  to  time.  These  suggestions  should  invariably 
be  carried  out  by  surgeons. 

The  abortive  treatment  amounts  to  nothing,  which  is  shewn  by 
so  much  having  been  Avritten  on  the  subject  with  still  no  recog- 
nized specific.  But,  of  course,  you  must  do  something,  and  the 
following  is  the  most  logical:  Keep  the  hand  elevated  and  the 
finger  enclosed  in  an  ice  bag,  this  keeps  down  excessive  hype- 
raemia,  aad  the  cold  also  has  a  deleterious  action  on  the  microbes. 
If,  in  spite  of  all  you  do,  the  process  goes  on  to  suppuration,  don't 
poultice,  render  the  part  aseptic  with  the  usual  care,  use  some 
local  angesthetic  as  Cocaine  or  Ethyl  chloride  spray  and  with  a 
clean  knife  make  an  incision  parallel  \^ith  the  long  axis  of  the  fin- 
ger, so  as  not  to  cut  the  tendon  in  two;  cut  carefully  as  the  pus 
may  be  just  under  the  skin,  and  by  carelessness  or  by  letting  the 
patient  do  the  cutting  by  jumping,  you  may  cut  down  to  the  ten- 
don unnecessarily,  or  the  pus  may  be  under  the  periosteum  and 
you  will  not  reach  it;  so  cut  carefull}^,  evacuate  the  pus,  irrigate  the 
cavity  with  a  strong  bi-cholride  solution  and  dress  aseptically. 
Flush  out  the  cavity  every  two  or  three  days  until  suppuration 
ceases. 

Furuncle.  —A  furuncle  or  boil  is  nothing  but  an  abscess  of  the 
skin.  They  are  more  frequently  seen  on  the  back  of  the  neck. 
There  may  be  only  one  or  two  and  again  they  may  extend  all  over 
the  body,  which  constitutes  a  disease  known  as  Furunculosis. 

Cause. — The  essential  cause  is  the  pus  genu.  The  pus  germ  is 
capable  of  penetrating  the  skin  in  rare  instances,  they  maj  gain 
admittance  through  a  hair  follicle  or  sodoriferous  gland,  and  when 


•      PRINCIPLES    OF    SURGERY.  57 

they  enter  by  these  chanoels  the}^  generally  locate  at  the  point  of 
entrance,  causing  9  iuruncle. 

Symptoms. — The  first  symptom  is  itching,  which  comes  from  a 
small  blotch  on  the  skin,  this  blotch  grows  larger  and  there  is  pain, 
redness,  swelling  and  increased  local  teinperature.  The  pus  soon 
appears  under  the  skin,  stretching  it  upward  and  unless  incised 
finally  burst  through  and  discharges. 

Tkeatment. — The  treatment  formerly  consisted  in  the  adminis- 
tration of  such  drugs  as  Calcium  sulphide.  Iron,  etc.,  which  were 
thought  to  prevent  their  formation.  This  is  not  true,  but  they  do 
good  if  the  patient  is  anemic  and  the  digestion  is  poor.  The 
prophylactic  treatment  consists  of  cleanliness.  Take  a  warm  bath 
three  or  four  times  a  week,  using  soap  free  from  alkalies  and  per- 
fumery; change  the  underclothing  frequently,  don't  scratch  the 
part  with  dirty  nails  and  thus  implant  fresh  infection.  It  this 
fails,  give  an  antiseptic  bath  once  a  week  of  Sulpho-naphtol  (gi  to 
a  tub  of  water).  When  a  furuncle  does  occur,  try  to  abort  it  be- 
fore it  points  by  touching  it  with  pure  carbolic  acid.  If,  however, 
it  goes  on  and  pus  forms,  don't  poultice,  but  render  the  part  aseptic 
and  incise  it  with  a  clean  knife.  Don't  try  to  squeeze  the  core  out 
and  thus  bruise  and  weaken  the  vitality  of  the  tissues,  but  with  a 
small  curette  scoop  out  the  necrotic  tissue,  irrigate  with  a  strong 
carbolic  acid  solution  and  put  on  an  aseptic  dressing.  If  the  patient 
be  an  important  one,  don't  envelope  the  bead  in  a  bandage,  but 
with  a  little  collodion,  paint  around  the  wound  and  apply  a  piece 
'^f  lint. 

Carbuncle.  —A  carbuncle  is  a  suppurative  and  gangrenous  in- 
flammation, the  toxic  germ  w  hich  causes  it  is  so  virulent  that 
death  of  the  tissues  result.  Some  authors  make  two  classes — Malig- 
nant and  Simple.  The  malignant  pustule  is  due  to  the  germ  of 
anthrax  and  is  distinct  from  a  carbuncle,  which  is  due  to  the  microbe 
of  suppuration.  Carbuncles  usually  occur  on  the  neck  or  buttocks, 
between  the  ages  of  forty  and  sixt^?.  It  may  be  from  one  to  four- 
teen inches  in  diameter.  Its  characteristic  feature  is  that  it  has  a 
cribriform  surface — that  is,  it  is  punctured  by  four  or  five  holes, 
whereas  a  furuncle  has  only  one  and  on  this  is  based  the  differen- 
tial diagnosis. 

Symptoms. — There  is  throbbing  pain,  redness,  swelling  and  in- 


58  PRINCIPLES    OF    SURGERY. 

creasea  local  temperature.  It  is  movable  and  feels  like  a  hard 
cartilagenous  mass. 

Treatment.—  If  the  carbuncle  is  seen  in  its  infancy,  exterminate 
it.  The  tissues  beneath  are  infiltrated  with  pus,  which  should  be 
evacuated.  Give  an  anaesthetic,  shave  and  render  the  part  aseptic, 
then  make  a  crucial  incision,  dissect  back  the  flaps  and  with  a 
curette  rerEove  the  necrotic  tissue,  clip  off  all  dead  fragments  of 
tissue  with  scissors,  irrigate  with  a  bi-chloride  solution  and  dress 
asepticalh^.  Irrigate  the  wound  daily  until  the  process  ceases. 
Sometimes  it  will  be  found  necessary  to  completely  exterminate 
the  carbuncle  as  if  3^ou  were  dealing  with  a  cancer.  Go  bej^oad 
the  infected  tissue  and  remove  it  bodily.  When  the  above  means 
fail,  and  the  germ  still  carries  on  its  deadly  work,  resort  to  the 
cautery,  take  a  thermo-cautery  and  burn  over  the  entire  surface. 

The  constitutional  treatment  of  all  suppurations  should  not  be 
neglected,  give  stimulants,  good  food,  and  for  the  pain  give  an 
anodyne. 


LECTURE  XIV. 


CLINICAL    FORMS    OF    SUPFUFvATION.— Continued. 

Abscess  of  the  Antrum. — An  abscess  of  the  antrum  is  a  circum- 
scribed collection  of  pus  in  the  Antrum  of  Highmore,  which  cavit}'' 
is  situated  in  the  Superior  maxilla.  This  cavity  opens  in^o  the 
nose  through  a  small  outlet,  which  is  only  covered  hy  mucous  mem- 
brane, the  roots  of  the  first  molar  and  second  bicuspid  teeth  usu- 
ally open  into  it  also. 

Cause.-— The  essential  cause  is  the  pyogenic  microbe,  which  may 
gain  admittance  through  the  roots  of  the  teeth  opening  into  it,  or 
through  the  opening  from  the  nose. 

Symptoms. — The  symptoms  are  pain  which  radiates  over  the 
whole  face.  If  the  pus  accumulates  swelling  will  result,  and  it 
may   go   on  to  such  an  extent  as  to  cause  protrusion   of  the  thin, 


PRINCIPLES    OF    SURGERY.  59 

bony  wall,  either  pushing  out  on  the  face  or  into  the  orbital  cav- 
ity, causing  protrusion  of  the  e^'^eball,  and  if  the  process  continues 
the  soft  tissues  alsc  become  infected.  The  abscess  may  break  into 
the  nose,  discharging  out  of  the  anterior  nares  or  posteiioi'  nares 
into  the  throat. 

Diagnosis. — The  diagnosis  is  based  on  the  symptoms,  one  side 
of  the  face  is  swollen,  the  eye  protrudes,  percussion  on  the  disease 
side  gives  a  dull  sound,  while  the  healthy  side  gives  a  tympanitic 
sound.  A  small  electrical  light  placed  in  the  mouth,  in  a  dark 
room  with  the  lips  closed,  gives  a  positive  diagnosis;  on  the  healthy 
side  the  light  will  be  diffused  through  the  bone  and  a  semi-lunar 
ring  of  light  will  show  below  the  eye,  but  the  light  on  the  diseased 
side  is  obstructed  and  does  not  show  below  the  eye. 

Treatment. — The  treatment  must  be  prompt,  or  else  disintegra- 
tion will  occur,  causing  serious  loss  of-  Hesh  and  horrible  disiigure- 
ment.  If  the  abscess  is  caused  by  a  diseased  tooth,  extract  it,  and 
with  a  gimlet  or  awl  bore  through  the  socket  of  the  tooth  into  the 
cavity  and  let  the  pus  escape.  But  if  you  find  the  teeth  healthy, 
don't  pull  them  out,  for  a  surgeon  has  no  more  right  to  sacrifice  a 
tooth  of  a  patient  than  he  has  to  sacrifice  a  limb.  In  this  case 
enter  the  antrum  through  the  canine  fossa.  Make  an  incision  an 
inch  above  the  first  bicuspid  tooth  down  to  the  bone,  and  with  an 
awl  bore  through  the  fossa  and  let  the  pus  escape.  After  evacua- 
ting the  pus  by  either  operation  flush  out  the  cavity  and  give  drain- 
age. Irrigate  the  cavity  daily  until  pus  stops  forming.  If  the 
abscess  is  very  extensive,  continue  the  boring  from  the  inside  of  the 
antrum  into  the  nasal  fossa  and  practice  continual  irrigation. 

.■\bscess  of  the  Livek. — This  consists  of  a  circumscribed  collec- 
tion of  pus  in  liver  tissue,  and  not  as  often  supposed  of  the  capsule 
or  peritoneal  covering. 

Causes. — The  causes  are  numerous.  The  essential  cause  is  the 
pyogenic  microbe,  the  predisposing  causes  are  stabs,  blows  or  con- 
tusions of  the  organ.  The  most  frequent  cause  is  tropical  influ- 
ences. Most  of  the  cases  seen  are  in  people  living  near  or  having 
recently  visited  the  Equator,  and  it  is  because  of  the  extreme  lia- 
bility cf  people  living  in  the  tropics  to  diarrhoea  and  dysp-ntery, 
which  is  caused  by  infected  water.  The  diarrhoea  and  dysentery 
is  followed  by  suppuration  of  the  intestines,   and  the  blood  from 


60  PRINCIPLES    OF    SURGERY. 

the  intestines  is  carried  directly  to  the  li^er  and  the  germ  is  also 
conveyed  along  \vith  it,  and  it  lodges  in  the  liver,  forming  a  throm- 
bus and  an  abscess  results. 

Symptoms.  —The  symptoms  are  very  vague  and  indefinite.  They 
come  on  at  first  very  slowly,  resembling  sub-acute  suppuration  in 
character,  the  patient  has  a  general  feeling  of  depression,  skin  is 
sallow,  tongue  foul  and  coated,  slight  evening  fever;  soon  night 
sweats  come  on,  and  there  is  general  debility  and  prostration;  the 
liver  begins  to  enlarge,  the  ribs  over  it  begin  to  bulge  and  on  pal- 
pation you  get  fluctuation. 

Diagnosis.—  In  order  to  make  a  diagnosis,  you  must  get  the  his- 
tory of  the  patient,  whether  or  not  he  has  at  some  previous  time 
received  a  stab  in  the  liver,  if  the  tropics  have  recentl}'^  been 
visited;  then  notice  the  appearance  of  the  skin  and  face,  the  pres- 
ence of  night  sweats  and  th'e  liver  tender  and  enlarged,  but  ivith 
all  these  syix  ptoms  you  can't  be  positive  in  your  diagnosis,  so  take 
the  old  axiom  of  surgeons,  ^'' Never  operate  for  suspected  pus  until 
you  jyrove  it  is  pus  hy  the  use  of  the  aspirator.''''  So  in  these  cases 
confirm  your  diagnosis  with  the  aspirator  before  operating.  Take 
a  small  aspirating  needle  four  or  five  inches  long,  attach  it  to  the 
syringe,  render  the  skin  aseptic  over  the  site  of  the  operation,  ste- 
rilize the  needle  over  a  fiame  and  insert  it  just  above  the  rib  over 
which  the  pus  is  suspected,  insert  it  freely  into  the  liver  tissue  and 
if  you  do  not  find  the  pus  where  you  suspected  it,  plunge  the  nee- 
dle in  other  directions  until  you  feel  the  lack  of  resistance  to  the 
needle,  which  indicates  that  it  has  entered  the  abscess,  withdraw 
the  piston  and  the  pus  will  come  into  the  barrel  of  the  syringe. 
The  pus  from  a  liver  abscess  is  peculiar,  being  of  a  dark  chocolate 
brown  color,  with  mucus  and  disintegrated  liver  tissue  mixed  with 
it. 

Tkeatment.  — After  making  a  positive  diagnosis  of  pus  you  must 
evacuate  it  at  once,  if  you  wait  it  may  infiltrate  the  tissues  and 
burst  into  the  abdominal  cavity,  causing  almost  sure  death.  Give 
an  anaesthetic,  render  the  part  aseptic  and  make  a  free  incision, 
and  if  necessary  remove  a  rib.  When  the  peritoneum  is  reached, 
if  you  find  the  visceral  and  parietal  layers  adhered,  you  can  pro- 
ceed with  the  operation,  but  if  they  are  not  adhered,  pack  the 
Avound   with  Iodoform  gauze   and  wait  a  week,  and  by  that  time 


PRINCIPLES    OF    SURGEPtY.  61 

they  will  have  become  adhered.  The  necessity  of  having  the  two 
layers  of  peiitoneum  adhered  is  to  keep  ihe  pus  out  of  the  abdomi- 
nal cavity.  Having  reached  the  liver,  take  an  aspirating  needle 
and  locate  the  abscess,  then  with  a  pair  of  artery  forceps  bore  a 
hole  into  the  abscess,  following  the  aspirating  nee'lle,  dilate  the  hole 
with  the  forceps  and  with  your  finger  break  down  any  trabeculae 
in  the  cavity,  irrigate  daily,  and  give  complete  drainage.  When 
operated  on  thirty  per  cent,  recover,  whereas  ninety  per  cent,  die 
without  the  operation. 

Abscess  of  the  Breast. — This  is  a  circumscribed  collection  of 
pus  in  the  mammary  gland. 

Causes. — The  essential  cause  is  the  pyogenic  germs,  which  reach 
the  gland  in  many  ways.  Physiological  engorgement  v^  ith  milk 
or  deficient  abstraction  of  miik  will  cause  it,  as  when  the  breast  is 
so  sore  that  the  baby  can't  be  allowed  to  nurse,  and  fissures  on  the 
nipple  is  another  common  cause.  They  are  sometimes  seen  in  men 
and  in  early  life,  but  are  more  common  in  women  soon  after  partu- 
rition. 

Symptoms. — There  is  throbbing  pain,  a  feeling  of  distention  and 
tension,  redness,  swelling  and  fluctuation,  and  if  the  breast  is  left 
alone  it  will  point  and  discharge.  The  constitutional  symptons  are 
slight  chili,  fever  and  anorexia. 

Treatment. — The  prophylactic  treatment  is  the  most  important, 
and  consist  of  the  care  of  the  breast  months  before  delivery.  In- 
quire into  the  condition  of  the  breast,  the  nipple  may  be  deeply 
sunken  into  the  breast,  and  when  the  child  is  born  it  won't  be 
able  to  catch  it  in  his  mouth;  in  this  case  instruct  the  woman  to 
pull  it  out  daily;  again  the  nipples  may  be  cracked  and  sore,  bathe 
them  and  touch  with  nitrate  silver  and  apply  antiseptic  solutions. 
After  the  birth  of  the  child,  see  that  the  breast  is  emptied  regularly, 
and  see  that  the  mother  doesn't  allow  the  child  to  nurse  only  from 
one  side;  vsash  off  the  nipple  with  a  boracic  acid  solution  after  the 
child  nurses  and  then  dust  with  an  antiseptic  powder,  such  as  calo- 
mel, but  be  sure  and  wash  this  off  before  allowing  the  child  to 
nurse  again,  or  you  will  cause,  as  in  the  case  of  calomel,  an  obsti- 
nate case  of  diarrhoea.  "When  suppuration  does  occur,  the  cura- 
tive treatment  consist  in  stopping  th<^  child  from  nursing  and 
in   removing  the  milk    with  a  breast  pump.     When   the  abscess 


62  PRINCIPLES    OF    SURGERY. 

forms,  as  will  be  shown  by  the  sj'mptoras,  liniments  may  be  used 
to  absorb  the  milk  (a  liniment  of  belladona  is  good),  purge  the 
woman  with  saliae  purgatives  and  give  opium  for  the  pain.  As 
soon  as  possible  you  must  evacuate  the  pus  by  making  a  free  in- 
cision, irrigate  the  cavity  and  give  free  drairage.  In  making  the 
incision  remember  your  anatomv,  how  the  tubules  approa.ch  the 
nipple  from  all  sides,  and  don't  cut  crosswise  and  sever  them,  thus 
causing  a  fistulous  opening  from  which  milk  constantly  oozes  and 
prevents  healing.  Make  your  incision  parallel  with  the  tubes  or 
as  the  spokes  of  a  wheel  are  to  the  hub,  make  a  large,  long  cut, 
break  up  the  trabecule  with  your  finger,  irrigate  daily  and  drain. 
Always  reiierber  that  a  large  incision  heals  as  quicklj^  as  a  small 
one,  and  when  operating  always  make  your  incision  large,  pro- 
vided there  is  no  large  artery  or  nerve  interposed. 

Abscess  of  the  Lung. — This  means  a  circumscribed  collection  of 
pus  in  lung  tissue  and  not  a  circumscribed  collection  of  tubercular 
matter. 

Cause. — The  essential  cause  is  the  pyogenic  microbe.  The  pre- 
disposing cause  is  anything  which  weakens  the  lung  tissue,  as  an 
attack  of  pneumonia,  which  may  leave  a  solid  spot  in  the  lung, 
which  constitutes  a  ^^ Locus  Minoi'is  Besistentim.''^  Or  the  germ 
may  come  from  the  air  on  some  foreign  body  as  a  cinder. 

Symptoms. — Pallid  face,  night  sweats,  cough,  emaciation  and 
expectoration.  Locally  we  have  an  area,  of  dullness,  loss  of  lung 
sound,  with  increased  vocal  fremitis. 

Diagnosis. — When  you  suspect  pus  never  operate  until  you  have 
confirmed  your  suspicion  with  the  aspirator.  Eender  the  part  and 
the  needle  sterile;  pass  the  needle  down  in  the  intercostal  space 
into  the  lung;  you  may  have  to  aspirate  in  several  places  before 
finding  the  pus.  After  securing  the  fluid  carry  it  to  a  microscopist 
and  find  out  whether  it  is  tubercular  matter  or  pus.  If  it  is  tuber- 
cular rcatter  don't  operate,  for  your  patient  is  doomed,  regardless 
of  all  the  new  serums;  but  if  it  is  pus  the  only  hope  is  an  early 
operation.  You  will  often  hear  of  tubercular  pus,  there  is  no  such 
thing;  pus  is  produced  by  the  bacillus  pj^ogenes  and  is  a  purilent 
material;  tubercular  matter  is  produced  by  the  Tubercle  bacillus 
and  therefore  distinct  from  pus. 

Treatment. — The  operation  for  the  removal  of  pus  from  the 
lungs  is  very  difficult,  but  although  difficult  it  is  your  duty  as  a 


PRINCIPLES    OF    SURGERY.  63 

surgeon  to  remove  it  anu  try  and  save  life.  Resect  a  rib,  reflect 
the  periosteun:,  and  with  bone  forceps  take  cue  two  or  three  inches 
of  the  rib,  carry  the  dissection  down  to  the  pleura,  open  the  pleura 
and  the  two  layers  will  be  generally  found  adhered,  but  if  they 
are  not  do  not  continue  the  operation  until  you  have  made  them 
adhere  by  packing  the  space  with  iodoforna  gauze.  Don't  cut  down 
into  the  lung  with  a  knife,  but  do  3'our  cutting  with  a  thermo- 
cautery, which  seals  the  vessels  as  fast  as  they  are  cut,  and  opens 
up  a  tunnel  down  to  the  pus,  irrigate  the  cavity  and  insert  a  drain- 
age tube  of  sufficient  size  to  give  free  drainage.  Flush  out  the 
cavity  daily  with  a  warm  antiseptic  solution. 

Abscess  of  the  Bbain. — This  is  a  circumscribed  collection  of 
pus  in  brain  tissue. 

Cause, — The  essential  cause  is  the  pyogenic  microbe,  which 
reaches  the  brain  in  the  majority  of  cases  through  a  suppurative 
disease  of  the  middle  ear,  which  space  is  only  separated  from  the 
bt-ain  by  a  very  thin  plate  of  bone. 

Symptoms. — The  symptoms  are  very  vague.  The  patient  is  irri- 
table, bad  temperament,  extravagant,  dissipated,  flighty,  delirious 
and  finally  convulsions  come  on.  There  is  headache  and  the  tem- 
perature may  be  high  or  sub-normal. 

Diagnosis. — The  diagnosis  is  difficult,  but  after  making  a  diag- 
nosis, it  is  sLill  harder  to  locate  the  seat  of  the  abscess.  Bv  a 
thorough  knowledge  of  the  physiology  of  the  brain,  you  can  find 
out  the  location.  Different  parts  of  the  brain  preside  over  differ- 
ent parts  of  the  body,  and  if  in  a  suspected  case,  the  hand  is  para- 
lyzed or  contracts,  we  know  the  abscess  is  somewhere  near  the  cen- 
ter for  the  hand,  or  if  the  patient  can't  articulate,  it  is  near  the  cen- 
ter for  speech.  In  locating  the  abscess  it  is  better  to  get  a  special- 
ist to  assist  you,  but  do  not  let  them  operate;  they  know  more 
about  the  brain  than  they  do  about  the  knife. 

Treatment. — After  making  your  diagnosis  and  locating  the  ab- 
scess, prompt  and  heroic  measures  should  be  adopted  to  save  your 
patient's  life,  for  if  you  wait  the  abscess  will  break,  causing  men- 
ingitis and  the  death  of  your  patient.  After  shaving  the  scalp  and 
rendering  it  aseptic,  mark  the  bone  over  the  site  of  the  abscess 
with  an  awl  or  else  after  cutting  up  the  scalp  you  will  loose  your 
bearings.     Dissect  up  ahorse  shoe  shaped  flap,  find   the  awl  hole, 


64  PRINCIPLES    OF    SURGERY. 

and  with  a  trephine  saw  out  a  circular  piece  of  bone,  cut  through 
the  meninges  and  if  3'ou  then  don't  find  the  pus  aspirate,  plunge 
the  needle  all  about  in  the  hrain  until  you  find  pus,  then  bore 
down  into  the  cavity  of  the  abscess  with  a  pair  of  artery  forceps, 
irrigate  and  drain  it  thoroughly.  The  piece  of  bone  is  usually  put 
back,  but  before  doing  so  notch  it  and  also  the  skin,  so  as  to  give 
exit  to  the  drainage  tube.  The  difference  in  trephining  and  tre- 
pan ing  is,  in  trephining  you  take  out  a  circular  piece  of  bone,  which 
can  be  replaced  after  the  operation.  In  trepaning,  which  is  the 
old  method,  the  bone  was  taken  out  with  an  instrument  like  an 
auger  used  to  bore  into  wood,  and  the  bone  came  out  in  shavings 
and  could  not  be  put  back,  and  a  piece  of  silver  plating  was  put  in 
its  place. 


LECTURK    XV. 


CLINICAL    FORMS    OF    SUP PURATION.— Continued. 

Before  discussing  suppuration  in  the  large  cavities  of  the  body,  it 
will  be  well  to  note  the  peculiarities  characteristic  of  the  process 
in  these  cavities.  First,  it  is  marked  by  the  rapidity  with  which  it 
is  diffused  over  the  lining  membrane;  second,  it  is  characterized 
by  the  fact  that  there  being  no  avenue  of  escape  for  the  pus,  it 
collects  in  large  quantities. 

Suppurative  Aktheitis. — This  is  a  suppurative  inflammation  at- 
tacking the  lining  membrane  of  joints.  A  joint  is  composed  of  two 
articular  surfaces  of  bone,  held  together  by  ligaments  and  lined  by 
synovial  membrane,  which  secretes  a  viscid  fluid  for  the  lubrication 
of  the  joint. 

Cause. — It  is  caused  by  the  pyogenic  microbe,  which  may  be 
introduced  directly  as  by  some  external  mechanical  cause,  as  a  slab 
or  bruise;  or  indirectly  by  being  conveyed  by  the  blood  to  the  joint, 
and  there  finding  a  weak  spot  it  localizes,  causing  the  trouble. 

Symptoms. — The  symptoms  are  simple.    There  is  an  acute,  burn- 


PRINCIPLES    OF    SURGERY.  65 

ing  pain,  due  not  so  much  to  the  severity  of  the  inflammaticn  or 
direct  etfect  oa  the  nerves,  but  to  pressure  from  accumulation  of 
pus.  If  it  is  the  knee  joint  the  limb  will  be  flexed,  mother  nature 
ilexes  the  limb  and  thus  increases  the  space  around  the  joint,  and 
relieves  the  pain  by  giving  room  to  the  exudations;  the  limb  is 
swollen,  there  is  f'^ver,  which  was  preceded  by  a  chill,  nausea, 
vomiting,  anorexia  and  the  sl:iu  is  flushed. 

UiAGxosis. — The  diagnosis  is  based  on  the  symptoms  and  history. 
The  patient  has  recently  stuck  a  nail  in  the  joint  or  received  a  stab 
wouad.  If  the  germ  was  introduced  indirectly  you  diagnose  by 
the  pain,  flexed  condition  of  the  limb,  fever  and  fluctuation.  But 
to  make  your  diagnosis  certain  you  must  confirm  it  with  the  ispira- 
tor. 

Treatment. — The  treatment  must  be  prompt  and  effective;  if  it 
be  delayed  the  pressure  will  become  so  great  as  to  rupture  the  cap- 
sule spontaneously  and  thus  tue  surrounding  tissue  becomes  infil- 
trated. Operate  early.  Take  the  knee,  for  example;  make  the 
limb  bloodless  with  Esmarch's  banaage,  render  the  part  aseptic; 
make  three  incisions  on  each  side  cf  the  joint  as  follows:  One  above 
the  joint,  one  opposite  it  and  one  just  below  it.  After  incising 
the  skin  take  a  long  pair  of  artery  forceps  and  bore  through  the 
cavity  until  the  forceps  show  on  the  opposite  side,  open  the  blades 
and  clip  the  skin  between  them;  now  take  a  rubber  tube,  clip 
numerous  holes  in  it,  catch  it  in  the  forceps  and  in  removing  the 
forceps  you  place  the  drainage  tube  in  position;  put  in  the  ihree 
tubes  in  this  manner  and  irrigate  through  them  daily  with  antisep- 
tic solutions;  dress  the  limb  aseptically,  using  plenty  of -absorbing 
cotton.  After  the  pus  stops  forming  remove  the  drainage  tubes 
one  at  a  time,  the  top  one  first,  then  in  two  or  three  days  the 
middle  and  about  the  fifth  day  the  third  one.  To  prevent  stiff- 
ness of  the  joint,  use  massage  and  passive  motion.  If  the  above 
treatur. ent  fails  from  too  long  delay  in  operating,  amputate  the 
limb  to  save  the  patient's  life. 

SuppuKATivE  Meningitis.  — This  means  suppurative  inflammation 
involving  the  membranes  of  the  brain  or  cord.  The  brain  is  located 
in  the  skull  and  is  invested  by  three  membranes,  viz..  from  within, 
outward,    Pia  Mater,  Arachnoid    and   Dura  Mater.      All  three  of 


66  PRINCIPLES    OF    SURGERY. 

these  membranes  are  liable  to  inflammation  if  from  any  cause  the 
pyogenic  microbe  reaches  them. 

Cause. — The  most  common  means  by  ^hich  the  germ  reaches 
them  is  through  a  compound  fractare  of  the  skull.  But  sonuetimes 
it  is  produced  without  any  injury  to  the  skull  and  we  say  the  germ 
A^as  conveyed  by  the  blood  and  found  a  weak  spot  in  the  meninges 
where  it  could  locate.  The  inflammation  may  be  localized  or 
diffuse;  when  locall2ed  it  becomes  so  by  nature  throwing  out  lymph 
and  building  a  \vaU  preventing  its  further  depredations;  in  other 
cases  nature  will  be  unsuccessful  and  the  inflamir. ation  will  be 
diffused  over  the  entire  surface  of  the  membrane. 

Symptoms. — Chills,  fever,  which  may  be  as  high  as  105  to  107 
degrees  F.,  intense  pain  in  the  head,  excitement  and  delirium,  giv- 
ing gradually  away  to  coma  and  paralysis. 

Diagnosis. — The  diagnosis  is  based  on  the  history  of  the  case, 
the  fact  of  previous!}^  having  a  compound  fracture  of  the  skull, 
opening  up  a  gateway  for  the  entrance  of  the  germs  or  having 
previously  had  concussion  of  the  brain,  which  weakened  the  tissues 
and  opened  upa^^Zocus  Minoris JResente7itiae'''  pressure,  headache, 
fever,  etc.,  all  help  in  the  diagnosis. 

Prognosis. — The  prognosis  varies;  if  the  suppuration  is  localized 
it  is  good,  but  if,  as  in  the  majority  of  cases,  the  whole  of  the  mem- 
brane is  involved,  the  prognosis  is  exceedingly  grave. 

Treatment. — The  principle  treatment  is  the  prophylactic.  As 
nine-tenths  of  the  cases  follow  compound  fractures  of  the  skull, 
the  prophylactic  treatment  is  the  proper  treatment  of  the  fracture 
and  the  wound  at  the  time  it  occurs.  Treat  the  fracture  as  a  major 
operation,  ancesthesize  the  patient,  shave  the  head,  for  it  is  im- 
possible to  render  the  scalp  aseptic  unless  you  do,  neither  can  you 
operate  with  the  hair  constantly  getting  in  your  way;  wash  the 
scalp  thoroughly  with  green  soap  and  water,  wash  the  soap  off 
with  alcohol,  and  lastly  wash  in  a  1-1000  bi-chloride  solution. 
Make  your  hands  and  instruments  sterile  and  proceed  io  this  man- 
ner: Make  the  wound  larger  if  necessary,  cut  off  all  pieces  of 
lacerated  tissue,  take  out  all  splinters  of  bone,  examine  the  dara 
and  if  it  is  bruised  and  bloody,  incise  it  and  remove  the  blood  clots; 
if  the  iDrain  is  also  injured  and  bloody,  remove  the  blood  anil  irri- 
gate  the   wound    with  a   1-2000   bi-chloride  solution,    arrest  all 


PRINCIPLES    OF    SURGERY.  67 

hemorrhage  and  if  the  brain  is  not  injured  you  can  allow  for  drain- 
age and  suture  the  wound  up,  but  if  the  train  is  injured  and  the 
tissues  bruispd  and  lacerated  and  the  bone  splintered,  pack  the 
Tvound  with  iodoform  gauze  a  ad  treat  it  as  an  open  wound.  If 
suppurative  meningitis  does  occur,  the  case  is  almost  hopeless,  but 
do  your  best  to  save  life;  take  out  a  large  piece  of  the  skull  (as 
large  as  tu'o  inches  in  diameter),  irrigate  the  wound  daily  and  give 
free  drainage. 

SuppuEATivE  Plecritis." — This  is  a  suppurative  inflammation  at- 
tacking the  pleura.  The  lungs  are  invested  by  an  envelope  of  se- 
rous membrane  called  the  pleura,  which  consists  of  tv^o  laj^ers, 
parietal  and  visceral,  the  layers  are  almost  in  contact  and  secretes 
a  fluid  which  lubricates  ihe  surfaces  and  makes  breathing  easy. 
The  suppuration  may  extend  over  the  entire  surface  of  the  pleura, 
which  constitutes  a  aisease  called  Empyaemia, 

Cause,  —The  essential  cause  is  the  pus  germ,  which  may  reach 
the  pleura  directly  as  a  stab  cr  cut  or  indirectly  through  the  blood. 

Symptoms. — The  process  is  usually  inaugurated  by  a  chill,  fol- 
lowed by  fever,  which  may  reach  as  high  as  105  degrees  F, ,  and 
continue  without  intermissions.  Anorexia,  bounding  pulse,  slight 
cough,  interference  with  respiration  from  the  collection  of  pus  in 
the  sack,  on  palpation  there  is  increased  dullness,  on  auscultation 
the  lung  sound  will  be  absent  and  there  is  sometimes  slight  bulg- 
ing in  the  intercostal  spaces. 

Diagnosis. — The  diagnosis  is  based  on  the  symptoms,  but  must 
be  confirmed  by  the  use  of  the  aspirator;  the  needle  must  be  thrust 
obliquel}^  between  ihe  sixth  and  seventh  ribs  and  if  your  diagnosis 
is  right,  you  will  get  pus  on  withdrawing  the  piston. 

Treatment, — The  operation  is  a  coirmoD  one,  and  must  be  con- 
sidered a  major  operation.  Aucesthesize  the  patient,  and  here  it  is 
admitted  by  the  advocates  of  Ether,  that  Chloroform  is  the  best 
anaesthetic.  After  making  everything  aseptic,  make  an  incision 
along  the  seventh  rib,  reflect  the  periosteum  and  reixove  the  rib; 
the  space  bet\^een  the  ribs  is  too  small  to  explore  the  cavity  satis- 
factorily, neither  can  you  use  a  large  drainage  tube.  ISTow  make 
an  incision  directly  into  the  pleural  cavity  and  the  pus  will  gush 
out.  Don't  allow  the  pus  to  escape  too  fast,  as  the  patient  may 
die  from  coilapse;  let  out  a  pint,  then  stick  your  finger  in  the  hole. 


68  PRINCIPLES    OF    SURGERY. 

"wait  a»^"hile  and  let  out  another  pint,  and  so  on  until  the  cavity  is 
empty.  Introduce  the  ano-er  and  see  if  the  lung  expands  and  has 
not  lost  its  elasticity,  irrigate  with  a  warm  antiseptic  solution 
(about  100  degrees  F.);  cold  solutions  will  produce  a  fatal  collapse. 
Insert  two  or  three  large  drainage  tubes  and  fasten  thera  so  they 
can't  come  out  or  drop  into  the  cavity,  irrigate  the  wound  daily. 
Don't  reirove  the  tubes  entirely  at  once,  take  them  out  about  a 
half  an  Inch  every  da}",  until  entiroly  removed.  In  fastening  the 
tubes,  some  surgeons  stitch  theno  to  the  skin,  but  this  is  painful. 
Take  a  large  safety  pin,  stick  it  through  the  tube,  fasten  to  the 
pin  a  piece  of  adhesive  plaster,  and  stick  this  on  the  skin  of  the 
chest.  As  the  tubes  are  removed,  clip  off  a  piece  of  the  plaster 
and  thus  shorten  it. 

Suppurative  Peeicakditis. — This  is  a  suppurative  inflammation 
attacking  the  pericardii] ra.  The  heart  is  invested  by  a  fibrous 
coat,  which  is  lined  by  a  serous  coat.  The  serous  coat  pours  out  a 
fluid  which  lubricates  the  surfaces  and  allows  the  heart  to  contract 
and  dilate  without  friction. 

Cause, — The  cause  is  the  pus  germ,  which  is  rarely  introduced 
from  without,  but  the  disease  is  set  up  as  a  complication  of  some 
other  infectious  diiiease. 

Symptoms. — The  s3^raptoms  are  not  as  plain  as  the  surgeon  would 
like  them  to  be.  There  is  usually  a  chill,  followed  by  fever,  rapid, 
bounding  pulse,  slight  bulging  over  the  heart,  percussion  over  the 
pericardium  gives  increased  dullness  and  there  is  difficulty  in  breath- 
ing. 

Diagnosis. — When  you  are  quite  confident  from  the  above 
symptoms  that  the  disease  exists,  you  are  perfectly  justifiable  in 
aspirating.  Introduce  the  needle  in  the  fifth  intercostal  space  one- 
half  inch  to  the  left  of  the  sternum,  carry  the  point  backward, 
upward  and  outward  about  three-quarter  inches,  and  the  cavity  is 
reached,  -which  can  be  told  by  lack  of  resistance.  There  is  on  re- 
cord by  one  operator  of  seventy-nine  cases,  in  which  the  aspirator 
was  used;  one  was  instantly  killed,  five  died  in  twenty-four  hours 
and  the  remainder  did  well  after  the  operation. 

Tkkatmp:nt. — Make  a  small  incision  about  one  inch  long  in  the 
fifth  intercostal  space,  one  inch  to  the  left  of  the  sternum,  going 
through  the  skin  and  muscles,  then  bore  aown  into  the  cavity  i\ith 


PRIXriPLES    OF    SURGERY.  69 

a  pair  of  artery  forceps,  irrigate  daily  through  the  drainage  tnbe, 
which  luust  be  soft,  and  must  not  be  introduced  far  enougli  to 
touch  the  heart  and  thus  cause  pain  and  discomfort. 

SuppuKATivE  PERiToxfTis  — This  is  a  suppurative  infiaramation 
attacking  tbe  peritoneum,  xlll  the  organs  of  the  abdomen,  v\ith 
a  few  exceptions,  are  covered  by  peritoneum,  which  is  frequently 
the  seat  of  disease. 

Cause. — The  cause  is  the  pus  germ.  It  may  be  introduced 
directly  by  a  stab  wound,  by  an  incision  by  a  dirty  surgeon,  and 
by  the  rupture  of  an  abscess  of  the  appendix,  fallopian  tube  or 
liver.      It  is  also  said  to  le  sometimes  infected  by  the  blood. 

Classificatiox. — Peritonitis  is  divided  into  acute  and  sub-acute. 
The  acute  is  sometimes  called  septic  peritonitis  and  the  sub-acute 
supptrative  peritonitis.  Both  processes  are  the  same,  the  only 
difference  is  in  their  onset,  post-mortem  appearance  and  the  pain. 
Septic  peritonitis  acts  quickly,  the  pain  is  excruciating  and  the 
patient  dies  before  pus  can  be  formed.  Suppurative  peritonitis  is 
a  slow  process,  frequently  circumscribed  and  amenable  to  surgical 
treatment. 

Symptoms. — The  first  symptoms  are  those  of  intense  shock, 
tbere  is  profound  ccUapse,  depression,  fever  with  no  remission  up 
to  107  degrees  F.,  pulse  rapid,  abdomen  swollen,  face  anxious  and 
pinched,  tongue  coatsd,  clammy  skin.  These  symptoms  soon  pass 
otf  and  the  skin  becomes  dry  and  red,  tongue  cracked,  pulse  bound- 
ing, abdomen  tympanitic,  pain  excruciating  and  excessive  vomit- 
ing. The  symptoms  then  seem  to  get  better,  but  is  really  a  sign 
of  the  death  of  your  patient. 

Tkeatmext. — Render  everything  clean  around  the  patient;  open 
the  abdomen,  flush  out  freely  with  saline  solutions  and  give  free 
drainage 


70  PRINCIPLES    OF    SURGERY. 


LECTURE    XVI. 


CLINICAL    FORMS    OF    SUFPUEATION.— Continued. 

SuppuEATiYE  Osteomyelitis. — This  is  ai:  acute  suppurative  in- 
flammation, affecting  the  medullary  cavity  in  bone  tissue.  It  is  of 
frequent  occurrence,  disastrous  in  its  results,  often  endangering 
the  life  and  limb  of  the  patient  when  not  diagnosed  before  the  later 
stages.  It  is  usually  seen  in  long  bones,  especially  the  femur,  and 
at  a  point  denoting  the  junction  of  the  epiphysis  and  diathesis.  It 
is  occasionally  seen  in  the  ribs,  clavicle  and  ilium. 

Causes. — The  indirect  causes  are  age,  sex,  cold,  traumatism  and 
acute  diseases.  The  direct  cauise  is  the  pyogenic  microbe.  This 
fact  vvas  not  admitted  up  to  fifteen  years  ago;  it  was  thought  to 
be  due  to  a  specific  microbe.  But  experiments  have  proven  that 
it  is  due  to  the  pus  germ,  as  germs  from  osteomyelitis  have  been 
cultured,  and  when  introduced  beneath  the  skin,  they  cauye  ab- 
scesses identical  ^ith  those  formed  by  the  p3^ogenic  microbe  and 
inoculations  from  these  abscesses  will  cause  in  an  animal  having  a 
diseased  bone  a  disease  parallel  with  osueomyelitis.  The  germ  is 
not  generally  introduced  through  a  w^ound,  it  floats  in  the  blood 
and  locates  in  a  weak  spoc  in  the  bone,  which  has  been  devlltilized 
by  Typhoid  fever,  measles,  etc.,  and  the  point  is  generally  at  the 
junction  of  the  epiphysis  and  diathesis,  as  this  point  has  less  vitality 
from  the  tissues  being  more  embryonic,  less  mature  and  therefore 
more  liable  to  bacterial  infection.  Again  the  blood  vessels  at  this 
point  have  very  poor  walls,  in  fact,  they  are  nothing  but  a  series 
of  channels  without  distinct  walls,  and  the}  are  four  cr  Ave  times 
larger  than  the  capillaries  which  convey  away  the  blood. 

Pathology. — In  suppurative  osteomyeliris  we  first  have  the  germ 
entering  the  circulation  through  the  skin,  tonsils  or  intestines,  it 
floats  in  the  blood  and  finding  some  place  in  the  medullary  cavity 
of  a  long  bone  in  which  it  can  localize  it  does  so,  causing  the  disease. 
The  capillaries  are  first  attacked,  causing  hj^peraemia,  exudation 
and  transudation  from  the  vessels,  which  is  rapidly  converted  into 
pus.     The  pus  is  thus  enclosed  in  a  bony  wall,  but  finally  b}^  pres- 


PRINCIPLES    OF    SURGERY.  71 

sure  it  spreads  through  the  Ha  version  canals,  reaching  the  peri- 
phery of  the  bone,  it  then  attacks  the  periosteum,  which  hnally 
gives  away,  and  it  infiltrates  the  paraperiosteaJ  tissue.  Then  we 
have  a  phlegmonous  suppuration  of  the  soft  tissues,  which  extends 
toward  the  surface  of  the  limb,  causing  necrosis  of  the  part  b}'' 
pressure  and  occluding  the  blood  vessels.  Eventually  a  fistula  is 
formed  through  which  the  pus  escapes.  In  ttie  abscess  cavity  of 
the  bone  there  is  found  a  piece  of  bone,  which  has  been  killed  by 
the  disease  and  has  separated  from  the  healthy  bone,  and  lies  in 
the  cavity  as  a  foreign  body,  this  is  called  the  Sequestriuiu.  The 
luvolucrura  is  the  bony  wall  which  holds  the  sequestriuin  and  the 
cloicae  is  the  opening  in  thelnvolucrum  to  permit  the  passage  of  the 
pus  through  the  fistulous  tract. 

Symptoms. — The  premonitory  symptoms  are  indisposition,  lassi- 
tude and  general  weakness.  These  are  socn  followed  by  a  chill, 
fever  rangiQg  from  103  to  104  degrees  F.,  with  no  remission,  pulse 
rapid  and  feeble,  breathing  shallow  and  difficult,  tongue  coated, 
and  cracked,  diarrhoea  and  delirium.  The  local  symptoms  are  the 
same  as  in  any  cast;  of  suppuration  where  the  products  are  confined. 
The  pain  vvhich  is  exquisite  is  not  localized,  but  usually  referred 
to  some  neighboring  joint.  It  is  described  as  an  intense,  boring, 
tearing,  breaking  paia  and  is  not  relieved  by  opium.  The  pain 
suddenly  disappears,  which  denotes  the  time  at  which  the  pus  es- 
capes from  the  bone  into  the  surrounding  tissue.  We  have  tender- 
ness exquisitively  marked,  especially  over  the  part  where  the  sup- 
puration commenced.  The  area  of  tenderness  will  mark  the  pro- 
gress of  the  disease.  Swelling  takes  place  only  after  the  -pus  escapes 
into  the  paraperiosteal  tissue.  Eedness  and  heat  are  due  to  the 
acute  inflammation,  and  also  doesn't  occur  until  after  the  escape 
of  the  pus  from  the  bone.  The  process  is  now  ver}^  rapid,  soon 
involving  the  whole  circumference  of  the  limb.  The  function  of 
the  part  is  necessarily  lost,  the  patient  resting  the  limb,  as  the 
least  jar  causes  intense  pain. 

Diagnosis. — As  the  surgeon  is  not  usually  called  until  during  the 
later  stages  of  the  trouble,  a  sinus  can  be  seen  leading  through  the 
soft  parts  down  into  the  bone.  The  sinus  will  be  surrounded  by 
granulations  or  proud  fiesh.  A  probe  passed  into*the  medullary 
cavity  will  usually  detect  the  sequestrium.     Rarely  has  the  surgeon 


72  PRINCIPLES    OF    SURGERY. 

the  earlier  stages  to  treat,  but  the  complications  resulting  after  the 
pus  has  escaped  from  the  bone.  An  early  diagnosis  is  irrportant 
that  the  successive  stages  may  be  aborted.  Ninety-nine  per  cent, 
of  post-mortems  for  dead  bone  show  osteomyelitis  to  be  the  cause. 
Differential  diagnosis  is  sometimes  impossible  and  requires  a  care- 
ful stud  J  of  the  various  diseases.  Inflammatory  rheumatism  may 
be  taken  for  it,  though  osteomyelitis  has  no  swelling  until  the  later 
stages.  It  may  be  mistaken  for  joint  inflammation,  suppurative 
periostitis,  phlegmonous  mflaramation  or  even  typhoid  feyer. 

Prognosis. — The  prognosis  depends  upon  the  intensity  of  the  dis- 
ease. It  is  sometimes  fatal  in  two  or  three  days;  so  virulent  is 
the  germ  that  death  ensues  before  suppuration  begins.  This  hasty 
termination  is  rare,  and  if  surgical  aid  is  employed  early  enough 
and  the  proper  measures  taken,  life  is  usually  saved,  but  the  use- 
fulness of  the  limb  is  scarcely  ever  restored. 

Ttkeatmekt.-— The  palliative  treatment  consists  in  the  adminis- 
tration of  purgatives,  put  the  patient  to  bed  and  elevate  the  limb, 
pack  the  part  in  ice,  thus  keeping  down  excessive  hyperaerria  and 
give  opium  for  the  pain.  There  are  three  stages  in  which  an 
operation  might  be  performed.  1.  Before  the  bore  is  perforated; 
2.  After  the  bone  has  been  perforated,  but  before  the  dead  bone 
has  separated  and  an  involucrum  formed;  3.  After  the  separation 
of  the  dead  bone  and  the  formation  of  the  involucrum.  The  opera- 
tion in  the  first  stage  consists  of  rendering  the  part  aseptic,  cut 
through  the  soft  tissues  down  to  the  bone,  reflect  the  periosteum 
and  chisel  a  small  hole  in  the  bone  and  allow  the  pus  to  escape, 
then  curette  out  all  the  dead  bone,  irrigate  with  bi-chloride  of  mer- 
cury and  dress  asepticali}''.  In  the  second  stage  cut  down  into  the 
phlegmonous  inflammation,  irrigate  and  disinfect  these  tissues,  find 
the  cloicae,  slightly  enlarge  it,  but  don't  chisel  into  the  bone  and 
tr}'^  and  take  out  the  sequestriura,  for  it  hasn't  become  separated 
as  yet,  and  you  are  liable  either  to  take  out  too  much  or  else  not 
remove  all  the  diseased  bone.  The  operation  in  the  third  stage  is 
the  most  common  and  is  called  Sequestrotomy.  Render  the  limb 
bloodless  with  Esmarch's  bandage,  rind  the  cloicae,  take  off  the 
roof  of  the  cavity  with  a  chisel,  remove  the  sequestrium,  thus  leav- 
ing a  troufi-h  in  the  bone,  curette  out  all  the  dead  bone,  disinfect 

DO  ' 

the  cavity  with  Peroxide  of  hydrogen  or  a  bichloride  solution,  close 


PRINCIPLES    OF    SURGERY.  73 

the  wound  and  wait  for  healing.  If  the  cavity  be  large,  allow  the 
capillaries  to  bleed  into  the  trough,  and  when  a  clot  forms  it  will 
form  a  bridge  for  the  new  bone  tissue.  Dr.  Senn  packs  the  cavity 
with  decalsifled  bone  chips,  which  greatly  facilitate  restoration  of 
the  part. 


LECTURE  XVII. 


ULCERATIOI^— FISTULA— SINUS. 

Ulceration, — An  ulcer  may  be  defined  as  a  solution  of  the  con- 
tinuity of  the  skin  or  mucous  membrane,  Yvhich  shows  no  intrinsic 
tendency  to  heal.  An  accurate  knowledge  of  an  ulcer  and  its  treat- 
ment is  necessary  to  every  practitioner.  They  are  difficult  to  treat, 
being  most  common  amongst  the  poor,  who  are  ill-fed  and  nnable 
to  lay  up  or  pay  for  the  proper  remedies  and  treatment. 

Divisions. — Ulcers  are  divided  into  superficial,  deep,  acute  and 
chronic.  Superficial  ulcers,  as  their  name  inaicates,  only  attack  the 
superficial  structures;  deep  ulcers  also  involve  the  deeper  struc- 
tures. Acute  ulcers  come  on  quickly,  run  a  definite  course  and 
subside;  a  chronic  ulcer  comes  on  slowl3\  shows  little  inflamma- 
tion and  are  hard  to  heal. 

Causes. — The  constitutional  causes  are  certain  infectious  diseases 
as  syphilis,  tuberculosis,  leprosy,  etc.  They  also  follow  disturb- 
ances to  tbe  nutrition  of  the  tissues,  as  in  cachexia,  anemia,  scor- 
butis  and  diabetes.  The  local  causes  may  be  a  blou  or  bruise,  ap- 
plication of  strong  caustics,  intense  heat  or  cold,  certain  disturb- 
ances in  the  circulation,  as  by  cutting  off  the  arterial  supply  by  a 
ligature  or  pressure  or  by  defective  venous  return,  causing  stagna- 
tion;  defective  trophic  influence,  as  seen  in  ihe  perforating  ulcer 
of  the  foot,  where  no  other  cause  can  be  given. 

Anatomical  Character. — An  ulcer  is  said  to  have  a  floor,  mar- 
gin and  an  underlying  or  surrounding  tissue.  The  floor  or  base 
is  the  depressed  central  part  of  the  sore;  it  is  below  the  skin  level, 


74  PRINCIPLES    OF    SURGERY. 

flat  and  covered  Avith  granulation  tissue,  which  varies  in  color  with 
the  type  of  the  ulcer.  The  margin  or  border  is  that  part  extend- 
ing from  the  floor  to  the  skin ;  it  msLj  be  vertical,  excavated  or 
sloping.  The  adjacent  tissue  is  hard,  dense  and  even  cartilagen- 
ous  in  texture,  from  the  spreading  of  the  inflammation. 

Diagnosis. — The  diagnosis  is  based  on  the  character  of  the 
wound  and  its  cause. 

Prognosis. — The  prognosis  depends  on  the  type  of  the  ulcer, 
cause  producing  it,  general  health  of  the  patient,  pecuniary  con- 
dition and  the  ability  of  the  attending  surgeon. 

Vaeieties. — There  are  many  varieties  described,  based  on  the 
cause  and  clinical  behavior. 

1.  Inflamed  ok  Tkadmatic  Ulcer. — This  form  is  always  pro- 
duced by  an  injury,  as  a  burn,  bruise,  etc.,  which  becomes  infected. 
It  is  not  a  deep-seated  ulcer,  and  is  covered  with  pale  granulation 
tissue  and  there  is  a  tendency  to  heal. 

Treatment.- — -This  form  yields  to  rest  and  disinfection;  apply 
moist  antiseptic  dressings,  which  must  not  be  removed  too  fre- 
quently and  the  tvound  soon  heals. 

2.  Indolent,  Weak  or  Callous  Ulcers. — This  is  an  ulcer  of  long 
standing,  which  perhaps  was  originally  a  traumatic  ulcer,  but 
from  improper  treatment  degenerated  into  this  type.  They  are 
not  deep,  and  the  margins  are  hard,  thick  arid  granulated. 

Treatment. — Make  the  wound  and  the  surrounding  tissue  clean 
and  siimulate  the  ceils  with  nitrate  of  silver,  ten  per  cent,  solution 
of  chloride  of  zinc  or  a  solution  of  copper  sulphate;  if  these  fail, 
touch  the  surfaces  \;\ith  a  red  hot  iron  or  dissect  out  the  dead  tissue 
and  dress  aseptically. 

3.  Exuberant  or  Fungous  Ulcers.- -This  type  is  just  the  reverse 
of  the  preceding.  It  makes  too  great  an  effort  toward  healing,  and 
the  granular  tissue  rises  above  the  level  of  the  surrounding  tissue; 
this  is  the  so-cali^d  '"''proud  flesh,"'''  Epidermization  is  impossible, 
but  in  the  effort  to  cover  it,  it  constricts  the  '•'■proud  flesh'''  and 
gives  it  a  pediculated  appearance. 

Treatment. — Disinfect  and  shave  off  the  superfluous  tissue  down 
even  with  the  skin,  slightly  cauterize  the  surface  with  nitrate  of 
silver,  so  as  to  obliterate  the  arteries  and  thus  prevent  its  further 
growth.     Dress  with  moist  antiseptic  dressings. 


PRINCIPLES    OP    SURGERY.  75 

4.  Ikkitable  or  ERirHisTic  LTlceks.  --This  type  of  ulcers  are  so 
sensitive  that  it  is  impossible  to  wash  them,  and  unless  the  part 
be  given  absolute  treatment  you  can't  cure  them.  Their  most  fre- 
quent site  is  the  rectum  or  around  the  margin  of  the  navel.  They 
are  deej)ly  excavated,  discharges  a  serous  pus  and   very  irritable. 

Treatment.-— Remove  the  cause.  If  it  is  the  rectum  paralyze 
the  sphincter  muscle,  paint  with  cocaine  and  either  dissect  it  out 
or  apply  some  escharotic,  such  as  carbolic  acid  or  nitrate  of  siher. 

5.  Phagedenic  or  Gangrenous  Ulcers. — This  ulcer  is  due  to  a 
microbe  of  great  virulence,  which  causes  rapid  cell  necrosis.  The 
ulcer  spreads  very  rapidly,  one  side  healing,  while  the  other  is  in- 
volving the  neighboring  tissues.  Their  most  frequent  site  is  on  the 
penis. 

Treatment.—  The  treatment  consists  of  perfect  fumigation  with 
sulphuric  acid  or  actual  cautery.  Whenever  an  ulcer  won't  heal, 
always  substitute  the  old  wound  by  a  burn  and  it  will  then  heal. 

6.  Varicose  Ulcers.  — This  is  the  most  frequent  type.  It  is 
caused  by  defective  venous  return  and  is  usually  seen  on  the  lower 
extremities.  The  valves  in  the  veins  give  way,  and  throagh  pres- 
sure in  the  veins  serum  escapes  into  the  surrounding  tissue,  causing 
the  ulcer. 

Treatment. — Remove  the  cause  and  thus  stop  the  transudation 
of  serum,  into  the  tissues.  Put  the  patient  in  bed,  elevate  the  limb, 
and  so  by  gravity  assist  the  venous  flow.  If  the  patient  is  poor 
and  can't  lay  up,  strap  the  leg  with  flannel  or  rubber  bandages 
from  the  toe  to  the  popliteal  space.  You  can  never  hope  to  cure 
the  ulcer  until  the  fluid  is  driven  out  and  kept  out  of  the  limb. 

T.  Trophic  Ulcers. — These  are  due  to  defective  nervous  supply 
and  are  difficult  to  treat,  as  you  can't  remove  the  cause. 

Treatment. — The  treatment  consists  of  rest  and  cleanliness  and 
the  use  of  antiseptic  dressings. 

8.  Specific  Ulcj:rs — This  type  is  due  to  specific  diseases,  as 
syphilis,  anthrax,  tuberculosis  and  glanders. 

Treatment. — The  treatment  must  be  on  general  principles,  if 
syphilis,  give  mercury;  if  tuberculosis,  build  up  the  general  health, 
etc.     Dress  the  ulcer  with  moist  antiseptic  dressings. 

General  Treatment  of  Ulcers. — ^Give  the  part  absolute  rest  and 
elevate  it  to  promote  venous  return  (a  dependant  position  aggra- 


76  PRINCIPLES    OF    SURGERY. 

Yates  tbe  conclition).  Remove  tbe  cause  producing  the  ulcer;  if 
due  to  syphilis,  give  Iodide  of  potash;  if  due  to  tuberculosis,  give 
cod  liver  oil;  treat  the  cause  that  the  result  may  be  removed;  if 
it  is  due  to  defective  circulation  elevate  or  use  warm  applications. 
Obtain  and  maintain  asepticity;  ail  ulcers  are  caused  by  a  microbe, 
and  therefore  j'^ou  must  employ  germicides,  in  solution  or  other- 
wise, as  a  dressing;  never  use  salves  or  vasaline.  If  these  methods 
fail  either  stimulate  with  nitrate  of  silver  or  help  mother  nature 
b}"  skin  grafting. 

FISTULA.  —  A-  fistula  is  an  abnormal  opening  from  the  skin  or 
mucus  njembrane  -into  a  normal  cavity;  as  an  opening  leading 
from  the  skin  into  the  pleural  cavity,  or  the  opening  made  in  the 
bladaer  by  a  surgeon.  Fistulas  are  named  acording  to  the 
anatomical  structure  involved,  as  V^esico-vaginal,  Recto-vaginal, 
Gastric,  Fistula  in  ano  etc.  They  are  caused  by  some  defective 
foetal  development  or  bv  pressure  causing  sloughing. 

Treatment. —  Freshen  the  edges,  bring  them  together  and  suture, 
using  proper  antiseptic  precautions. 

SINUS.  —  A  sinus  is  an  abnormal  opening  from  the  skin  or  mucous 
membrane  into  an  abnormal  cavity,  as  from  the  skin  down  into 
the  involucrum  of  the  bone,  or  from  the  skin  or  mucous  membrane 
into  a  tubercular  abscess. 

Treatment.  —  A  sinus  can  only  be  cured  by  splitting  open  the 
cavity  it  leads  from,  and  by  thorough  irrigation  you  remove  the 
cause  and  the  sinus  will  heal. 


LKCTURE  XVIII. 


GAISTGRKNE. 

Gangrene,  Mortification,  Necrosis  and  Sphacelus,  aresynomy- 
raous  terms  used  to  designate  the  death  of  the  tissues  '^en  masse.'''' 
These  terms,  as  used  by  certain  English  writers  of  former  days,  bore 
a  different  significance  from  that  of  to-day.     With  them  gangrene, 


PRINCIPLES    OF    SURGERY.  77 

mortification  and  sphacelus  meant  deatti  of  the  soft  tissues,  while 
necrosis  was  restricted  in  its  meaning  to  death  of  bone.  A  more 
modern  and  scientific  distinction  has  teen  drawn  between  these 
terms;  recent  literature  speaks  of  gangrene,  mortification  and 
sphacelus  as  death  of  a  pare  exposed  to  the  atmosphere,  a  super- 
ficial region,  where  putrefactive  bacteria  gain  ready  access;  while 
it  describes  necrosis  as  death  of  an  internal  organ  or  an  area  which 
is  unattended  by  putrefactive  changes. 

Causes, —The  general  causes  are  debility  and  certain  constitu- 
tional diseases,  as  starvation,  old  age,  long  sickness,  ej^cessive  loss 
of  blood,  Bright's  disease,  diabetes  and  anything  which  will  vitiate 
the  tissues.  The  local  causes  are:  1.  [nterference  with  the  arte- 
rial supply.  It  is  essential  to  the  life  and  vitality  of  tissues  that 
they  should  have  an  adequate  amount  of  tlood  reaching  thera,  and 
anything  w^hich  interferes  with  the  blood  supply  will  therefore  cause 
death  of  the  tissues.  These  conditions  are  trauma,  as  a  stab 
\^ound  penetrating  some  large  artery;  pressure,  as  from  a  tight 
plaster  cast;  licjation ;  spasms  of  arteries,  thrombosis  and  em- 
bolism. 2.  Interference  with  venous  return.  This  is  as  important 
as  the  foregoing  cause  of  gangrene,  as  for  the  tissues  to  be  in  a 
healthy  condition,  not  only  must  the  arterial  supply  be  normal, 
but  the  venous  blood  must  be  carried  off  to  be  freshly  oxydized; 
thus  anything  which  staysthis  venous  return  will  cause  thetrouble. 
It  may  be  due  to  a  tramnatic  blow,  as  a  stab,  which,  (occludes  some 
large  vein;  pressure  of  tight  bandages,  ligature,  thrombus  or  era- 
bolus.  3.  Defective  nervous  supply.  For  a  tissue  to  thrive,  not 
only  must  it  have  proper  arterial  supply  and  be  drained  of  its  \en- 
ous  blood,  but  must  have  its  trophic  nerves  in  a  proper  condition, 
and  anything  interfering  with  their  normal  function  is  liable  to 
cause  gangrene,  as  by  destroying  the  vaso-motor  nerve  to  a  part, 
anemia  and  gangrene  follow.  4.  Direct  action  of  destructive 
agents  on  tissue.  As  a  car  wheel  passing  over  a  limb,  crushing  it, 
pressure,  as  bad  sores,  inflammation  may  cause  it,  exposure  to  ex- 
cessive cold,  or  intense  heat,  and  the  direct  action  of  caustics. 

Yaeieties. — There  are  two  varieties  of  gangrene — Dry  and 
Moist.  Dry  gangrene  is  due  to  interference  with  the  arterial  sup- 
ply to  the  part,  as  the  result  of  obliteration  or  plugging  of  an 
artery,  without  any  abnormality  of  the  veneris  return.      The  part 


78  PRINCIPLES    OF    SURGERY. 

becomes  dry,  bard  and  atropbied  almost  as  soon  as  tbe  arterial 
blood  is  cut  off  and  Avbat  little  blood  was  in  tbe  part  is  soon  drained 
off  by  tbe  veins.  Tbe  skin  soon  becomes  leatbery;  tbe  constitu- 
tional symptoms  are  few,  because  of  non-infectioQ  and  tbe  absence 
of  decomposition.  Tbe  separation  between  tbe  dead  and  living 
tissue  takes  place  slowly  and  witb  little  danger  to  tbe  life  of  tbe 
patient. 

Moist  gangrene  is  produced  by  some  interference  to  tbe  venous 
return,  tbe  arterial  supply  being  normal.  Tbis  causes  tbe  tissues 
to  become  swollen,  water  logged  and  surcbarged  witb  venous 
blood.  Tbe  part  soon  becomes  infected  and  putrefies;  tbe  absorp- 
tion of  tbe  decomposition  products,  causes  general  constitutional 
symptoms  to  supervene.  Often  we  bave  a  rapid  and  fatal  termi- 
nation due  to  acute  septicaemi*'. 

Symptoms. — The  general  symptoms  are  due  to  tbe  absorption 
into  tbe  system,  tbe  products  of  decomposition.  Tbe  symptoms 
of  septicaemia  follow:  Cbills,  fever,  apatby,  drowsiness,  face 
asby,  then  becoming  yellowish,  pulse  rapid  and  small,  respirations 
shallow,  clammy  perspiration  and  finally  death.  Tbe  local  symp- 
toms are  important,  being  more  distinct  than  tbe  general.  There 
is  pain  Which  from  the  first  stages,  changes  in  intensity.  In  the 
earlier  stages  it  is  intense,  whether  the  trouble  is  due  to  a  tight 
bandage,  an  embolus  or  to  acute  inflammation.  It  subsides  grad- 
ually, and  when  quite  lost  it  shows  that  tbe  trouble  has  resulted 
in  perfect  death  to  the  part  and  the  nerves  within  it.  There  is 
tenderness  (pain  elicited  on  pressure),  tbis  is  of  value  in  the  diag- 
nosis, it  is  acute  in  tbe  earlier  stages,  gradually  subsiding  until  tbe 
part  has  become  devitilized,  when  it  is  absent  altogether.  The 
temperature  varies.  If  tbe  gangrene  be  due  to  plugging  of  the 
artery  to  the  part,  the  temperature  of  the  anemic  part  at  once  falls 
to  sub-normal.  If  due  to  acute  inflammation,  it  is  first  high,  but 
as  soon  as  tbe  parts  become  devitilized,  tbe  temperature  falls  below 
normal.  The  pulse  in  the  artery  to  the  part  is  absent  when  gan- 
grene is  complete,  and  is  cue  guide  to  a  correct  diagnosis.  Swell- 
ing is  present  in  tbe  moist  variety,  due  to  tbe  surcharged,  water- 
logged condition  of  the  tissues,  but  in  dry  gangrene  it  is  absent, 
the  part  becomes  shriveled  and  atrophied  from  lack  of  moisture. 
Emphysema  is  present  in  moist,  but  absent  in  dry  gangrene.    When 


PRINCIPLES    OF    SURGERY.  79 

present,  it  can  be  elicited  by  manipulation,  as  a  dry,  crackling, 
resonant  sound.  The  color  depends  on  the  variety,  if  due  to  de- 
fective arterial  supply,  the  part  is  pale  and  anemic;  after  the 
tissues  die,  by  virtue  of  a  chemical  change,  it  becomes  livid,  blue, 
black,  blistering  and  showing  all  the  usual  putrefactive  changes. 
The  odor  in  the  dry  variety  is  nil,  but  in  the  moist  variety  a  most 
horrible,  unbearable  stench  is  constantly  exhumed.  The  line  of 
demarcation  is  not  a  symptom,  but  is  a  phenomena  often  observed  . 
It  is  a  line  dra^vn  by  nature  between  the  dead  and  living  tissue. 

Diagnosis  —The  diagnosis  is  usually  plain,  both  by  the  nose  and 
sight.  The  dead  tissues  have  an  appearance  and  smell  not  easily 
mistaken.  Sometimes,  as  in  strangulated  hernia,  it  is  difficult  to 
differentiate  between  gangrene  and  congestion  of  the  part,    i 

Prognosis. — The  prognosis  depends  on  the  type,  age,  general 
health  and  surroundings  of  the  patient. 

Treatment. — -The  prophylactic  treatment  consists  of  medicinal 
and  dietetic  measures.  Use  every  means  possible  to  favor  the 
blood  supply  and  remove  every  condition  favorable  to  the  develop- 
ment of  gangrene.  If  the  cause  of  the  threatened  gangrene  can 
be  removed  do  not  hesitate,  but  act.  If  it  be  a  strangulated 
hernia,  divide  the  constricting  rino;;  if  a  tight  plaster  cast,  remove 
it;  if  inflammation  threatens  to  terminate  in  gangrene,  relieve  the 
tension  by  a  free  incision.  Try  and  favor  the  establishment  of  the 
collateral  circulation;  lower  the  part,  to  favor  the  arterial  supply, 
elevate  it  to  favor  venous  return,  preserve  the  w^armth  of  the  limb 
with  hot  applications  and  pay  special  attention  to  asepsis  and  anti- 
sepsis to  prevent  the  invasion  of  putrefactive  bacteria.  The  cura- 
tive treatment  consists  of  sustainincj  the  strength  with  nourishincr 
food  and  stimulants,  as  quinine  and  strychoia.  If  the  patient  is 
young  and  robust,  it  is  best  to  wait  for  the  line  of  demarcation; 
but  if  old  and  feeble  and  the  disease  shows  no  signs  of  becoming 
limited,  an  early  opsration  for  the  removal  of  the  dead  tissue  must 
be  resorted  to,  thus  minimizing  the  danger  of  general  septicaemia 
from  absorption  of  ptomaines  and  toxins. 


80  PRINCIPLES    OF    SURGERY. 


LECTURE 


CLTTs^ICA.L    FOEMS    OF    GA^^GRENE. 

PtjoGRESsivE  Gaxgkexe. — This  is  a  moist  gangrece  which  fol- 
lows injuries  to  the  soft  tissues  and  is  characterized  by  rapid  ex- 
tension and  fatal  termination. 

Cause. — This  variety  follows  large  wounds,  as  after  extirpation 
of  a  breast.  It  is  still  a  mooted  question  whether  it  is  caused  by 
a  specific  germ.  The  streptococcus  pyogenes  is  generally  found 
associated  \\ith  the  disease  and  its  virulent  action  is  accounted  for 
by  the  lowered  vitality  of  the  tissues. 

Symptoms. — The  symptoms  usually  appear  in  a  few  hours.  The 
local  symptoms  are  evinced  at  the  point  of  infection.  The  wound 
is  swollen,  red,  angry  looking,  the  surrounding  tissues  have  a  crim- 
son tint  and  there  is  a  sanious  discharge  from  the  wound.  The 
tissues  then  become  blue,  then  black  and,  in  fact,  you  have  all  the 
signs  of  mortification  before  you.  The  tissues  crepitate  under  3^our 
fingers,  caused  from  the  bursting  of  air  bubbles,  the  skin  is  thrown 
up  in  blisters,  the  patient  is  unconscious,  the  discharge  is  putrid 
and  nine  out  of  ten  such  cases  die.  The  constitutional  symptoms 
caused  by  the  absorption  of  the  toxins  are  high  fever,  preceded  by 
a  chill,  hurried  respirations,  quick,  feeble  pulse,  the  patient  is  irri- 
table and  anxious,  then  comes  on  stupor,  delirium  and  lastly  pro- 
found coma. 

Treatment.  The  most  important  treatment  is  the  preventive, 
which  consist  in  cleanliness.  If  a  limb  is  broken  and  the  wound 
is  dirty,  don't  let  others  clean  it,  do  it:  yourself,  remove  all  splin- 
ters of  bone,  clip  off  all  small  pieces  of  lacerated  tissue  and  dress 
aseptically.  After  the  disease  has  commenced  don't  wait  for  any- 
thing, operate  at  once.  Formerly  the  line  of  demarcation  was 
waited  for  with  the  result  that  every  case  proved  fatal  before  the 
line  was  formed.  In  operating  never  use  Esmarch's  bandage, 
as  it  raa}'^  force  diseased  tissue  and  pus  into  healthy  tissue,  causing 
further  complications.  Slightly  elevate  the  part  and  apply  a  tour- 
niquet.    Amputate,  if  it  be  a  limb,  as  far  from  the  diseased  tissue 


PRINCIPLES    OF    SURGERY.  81 

as  possible,  only  thinking  of  the  patient's  life  and  not  his  limb;  of 
conrse,  you  must  use  judgment  and  remember  the  nearer  you  go 
to  the  trunk  the  greater  will  be  the  shock  and  general  danger.  If 
the  operation  is  successful  the  symptoms  will  subside  in  four  or 
five  daj's.  If  sepsis  increases,  remove  the  dressings,  and  as  a  last 
hope  resort  to  continual  antiseptic  irrigation  and  stimulation. 

Senile  Gangeene. — This  is  a  specie  of  gangrene  which  attacks 
old  people,  and  is  due  to  some  degenerative  changes  in  the  arteries, 
causing  obstruction  to  the  blood  supply.  When  I  say  it  occurs  in 
old  people,  I  mean  people  with  diseased  arteries,  no  matter  if  they 
are  thirty  or  seventy.      "^  7nan  is  as  old  as  his  arteries.'''' 

Cause. — It  is  usually  caused  by  some  form  of  Endarteritis,  which 
may  be  from  excessive  cirinking.  The  disease  is  more  frequently 
located  on  the  great  toe. 

Symptoms.  — Premonitory. — A  man  v^ill  come  to  you  between  the 
ages  of  forty  and  seventy,  who  has  either  led  a  fast  life  or  has  in- 
herited artheromatous  degeneration  and  will  complain  of  a  tingling 
sensation  in  his  big  toe.  When  he  walks  it  feels  like  there  is  a 
foreign  body  between  his  foot  and  the  ground,  the  foot  may  be 
red  and  swollen  and  you  ma}''  diagnose  an  ingrowing  nail. 

Developed.  —Soon  the  tissues  become  a  dusky  red,  gradually 
turning  blue,  then  black;  there  is  no  swelling  or  odor,  the  toe  be- 
comes dry  and  wrinkled,  there  is  no  line  of  demarcation  between 
the  diseased  and  healthy  tissue  and  if  rature  doesn't  stop  the  pro- 
cess it  will  extend  &p  on  the  foot  a,nd  leg.  The  constitutional 
symptons  are  not  well  marked. 

Pkognosjs. — The  prognosis  is  generally  good,  as  the  line  of  de- 
marcation usually  forms  and  gives  a  guide  to  the  surgeon. 

Treatment.  — The  prophylactic  consist  in  treating  the  premoni- 
tory symptoms.  Elevate  the  limb,  keep  the  part  warm  and  clean, 
scrub  the  toe  with  a  bi-chlroride  solution  to  prevent  infection,  pro- 
hibit tight  shoes  and  wrap  the  part  in  cotton.  If  gangrene  does 
develop,  and  is  progressing  slowly,  wait  for  nature  to  form  the 
line  of  demarcation;  but  if  it  progresses  rapidly  and  shows  no 
signs  of  abating,  operate  at  once.  The  amputation  should  be  per- 
formed just  belovN  or  above  the  knee. 

Diabetic  Gangrene. — This  specie  of  gangrene  occurs  in  combi- 
nation with  a  disease  known  as  Diabetes,  or  sugar  in  the  urine. 

6 


82  .  PRINCIPLES    OF    SURGERY, 

The  pathology  of  the  disease  is  not  understood,  but  is  probably 
due  to  brain,  liver  or  kidney  trouble.  Besides  sugar  in  the  urine, 
there  are  eruptions  on  the  skin,  as  furuncles,  carbuncles  and  some- 
times local  gangrene.  This  localized  gangrene  may  occur  on  any 
part  of  the  body,  but  usually  occurs  on  the  leg. 

Symptoms.  — -The  symptoms  are  redness  and  congestion  of  the 
affected  part,  turning  yellow,  purple,  then  black.  The  line  of  de- 
marcation usually  forms,  but  occasionally  the  trouble  spreads  and 
death  results  from  septicaemia. 

Treatment. — The  prophylactic  treatment  consist  of  treating 
the  cause.  Put  the  patient  on  a  rigid  diet  containing  no  sugars  or 
starches.  Feed  on  steaks  and  green  vegetables  and  use  saccharine 
as  a  sweetening  agent.  The  fact  that  diabetic  people  are  alv^ays 
liable  to  gangrene,  should  make  you  careful  in  consenting  to 
operate  on  them,  unless  the  patient  is  suffering  from  diseases  like 
hernia  and  appendicitis,  when  you  should  not  hesitate.  After  the 
gangrene  is  apparent,  vtatch  the  disease  aad  if  the  line  of  demarca- 
tion forms,  clip  off  the  diseased  tissue,  disinfect  and  dress  with  anti- 
septic dressings.  But  should  the  disease  progress,  heroic  surgery 
will  be  the  last  resort. 

Decubitus  Gangrene. — This  specie  cf  gangrene  is  due  to  pres- 
sure, as  a  bed  sore  or  from  improperly  applied  splints. 

Symptoms.  —There  is  a  tingling  sensation  about  the  part,  with  a 
dusty  redness,  turning  yellow,  blue  and  black.  If  the  part  is  not 
relieved  of  the  pressure  it  sloughs,  emitting  foul  gases,  and  bloody, 
acrid  discharges. 

Treatment. — The  most  important  is  the  prophylactic.  In  ap- 
plying a  splint,  see  that  it  is  w^ell  padded.  When  your  patient  is 
confined  to  the  bed  for  a  long  time  see  that  no  one  area  of  the 
body  is  kept  from  a  proper  supply  of  blood  longer  than  three 
hours,  keep  the  back  clean  and  bathe  it  with  alcohol  once  or  twice 
a  week  to  harden  the  tissues.  "When  a  sore  is  threatened,  remove 
the  cause,  which  is  pressure.  If  the  patient  is  financially  able,  get 
a  water  bed;  if  not,  use  a  corcmon  rubber  bag  or  towels.  When 
the  process  does  occur  you  must  treat  it  heroically  or  the  loss  of 
tissue  will  be  frightful.  Render  the  part  clean,  apply  moist  anti- 
septic dressings,  and  as  soon  as  the  necrotic  tissue  comes  away  dust 
the  wound  with  iodoform  and  apply  an  antiseptic  dressing. 


PRINCIPLES    OF    SURGERY,  83 

Noma  or  Canckum  Oris.  — This  is  an  exceedingly  rare  disease;  it 
attacks  the  cheeks,  usually  of  children  between  the  ages  of  three 
and  four.  It  occurs  in  epidemics  amongst  the  poverty-stricken 
chiklren,  vvbo  have  poor  food,  badly  clad  and  consequently  suffer 
from  lowered  vitality.      It  is  seen  following  eruptive  fevers. 

Syis[ptoms. — There  appears  on  the  mucous  membrane  of  the 
moutn  a  livid  spot,  which  turns  first  red,  green  and  lastly  black. 
This  extends  through  the  cheek  and  opens  on  the  skin,  blebs  and 
blisters  form,  emitting  foul  gases  and  discharges.  The  process 
may  extend  to  the  gums,  causing  loss  of  teeth,  and  even  to  and 
causing  necrosis  of  the  maxilla. 

Treatment. — Strict  hygeine  and  proper  food  and  clothing  will 
render  the  disease  improbable.  The  onrative  treatment  consists  of 
thoroughly  removing  the  diseased  tissue,  cauterize  the  surface,  and 
if  recovery  follows  do  a  plastic  operation.  Sustain  the  strength 
with  stimulants  and  nutritious  food. 

Hospital  Gangrene. — This  is  a  contagious  variety  of  wound  in- 
fection, which  occurs  in  crowaed  v\  ards.  The  microscopist  and 
bacteriologist  would  be  pleased  to  see  a  case  of  this  disease,  but 
since  the  days  of  asepsis  and  antisepsis  the  disease  has  not  been 
known.  We  do  not  know"  whether  it  is  due  to  a  specific  microbe 
or  not.  It  attacks  wounds  four  or  five  days  after  they  are  made, 
causing  acute  progressive  gangrene,  which  usually  ends  fatally. 

Symptoms. —The  constitutional  symptoms  are  not  well  marked. 

Locally  the  wound  looks  angry,  red  and  inflamed;  next  it  be- 
comes yellowish  in  color,  the  tissues  are  soft  and  a  foul  smelling 
discharge  is  emitted.  It  gradually  spreads,  literally  eating  away 
the  tissues. 

Prognosis. — Eegardless  of  treatment  fifty  per  cent.  die. 

Treatment. — Prevent  the  disease  by  modern  aseptic  naethods. 

When  the  disease  occurs,  substain  the  strength  with  stimulants 
and  good  food,  render  the  part  aseptic  and  take  out  the  tissue  until 
you  reach  healthy  tissue,  cauterize  it  and  dress  antiseptically. 


84  PRINCIPLES    OF    SURGERY. 


LECTURE  XX. 


SHOCK. 


Shock  may  be  defined  as  profound  depression  of  all  the  vital 
powers.  It  has  long  been  known  that  patients  vi  ho  met  with  acci- 
dents or  underwent  operations,  not  of  themselves  necessarily  fatal, 
often  died  without  an.  explanation.  In  clearing  up  this  phenom- 
ena, the  English  surgeons  for  once  got  ahead  of  the  scientific  Ger- 
man students. 

Typical  Case. — Suppose  a  man  fell  from  a  house  and  fractured 
his  leg.  When  gently  put  on  a  litter  he  makes  no  attempt  at 
movement  or  speech,  his  face  is  pale  and  pinched,  his  eyes  are 
sunken,  he  has  a  vacant  stare,  no  expression,  pulse  rapid  and 
thread-like,  respiration  shallow  and  sighing,  skin  covered  with  a 
cold,  clammy  sweat,  temperature  sub-normal,  he  replies  to  ques- 
tions with  indifference,  there  is  no  coma,  but  apathy,  spinchters 
relaxed  and  feces  pass  involuntarily,  he  lays  perfectly  still,  not  be- 
cause his  muscles  are  paralyzed,  but  simply  do  not  act.  This  is  a 
clinical  picture  of  shock,  and  unless  prompt  measures  are  taken 
often  proves  fatal. 

Causes. — The  causes  of  shock  are  numerous,  and  in  fact,  may 
be  produced  by  almost  anything.  Pain  long  continued  will  bring 
about  the  condition,  it  being  common  before  the  advent  of  anges- 
thetics.  Extensive  burns,  v^here  the  cutaneous  extremit}^  of  the 
nerves  are  destroyed;  extensive  injuries,  though  the  pain  be  insig- 
nificant, as  in  a  dislocated  bone,  crushing  wounds  in  railroad  acci- 
dents, etc.;  excessive  hemorrhage,  as  where  a  tourniquet  slips  in 
an  amputation;  operations  on  the  genital  organs,  blows  on  the 
head,  jugular  vein,  testacies  and  stomach  and  mental  emotion  will 
also  bring  on  shock.  People  at  both  extremes  of  life  are  more  lia- 
ble to  shock.  Women  are  less  liable  to  shock  than  men;  invalids 
less  than  robust  miCn;  a  person  with  a  quick,  nervous  temperament 
is  more  liable  than  a  slow,  stupid,  phlegmatic  person  whose  senses 
are  not  keen  or  perceptive.  A  patient  who  goes  on  the  operating 
table  with  gloomy  dreads,  suffers  more  from  it  than  one  who  goes 


PRINCIPLES    OF    SURGERY.  86 

in  confidence  and  hope;  so  always  send  your  patient  on  the  table 
with  an  assurance  of  a  speedy  recovery,  and  with  faith  and  con- 
fidence in  your  ability.  Alwa3''s  tell  a  patient  what  he  has  got  to 
go  through,  then  let  hira  decide  for  himself.  If  he  decides  to  be 
operated  on,  no  matter  how  seriously  you  think  of  the  operation, 
it  is  your  duty  to  cheer  bira  up  with  your  successes  in  the  opera- 
tion, and  send  him  to  the  operating  table  in  a  condition  to  prevent 
shook.  Mental  emotion,  as  mentioned  above  as  a  cause  of  shock, 
may  seem  strange,  but  often  causes  it,  as  the  hearing  of  the  death 
of  a  near  relative  or  having  lost  a  fortune.  In  a  college  in  Europe 
the  students,  having  a  grudge  against  the  janitor,  decided  to  hold 
a  mock  trial,  condemn  him  and  go  through  an  execution.  The 
janitor  was  carried  to  the  forest  and  condemned  to  die,  he  took  it 
as  a  joke  at  first,  but  finally  got  scared  and  begged  for  mercy, 
but  the  students  wanted  revenge.  He  was  blindfolded,  his  head 
laid  on  a  block  and  the  executioner  told  to  chop  it  off.  He  was 
struck  back  of  the  neck  with  a  vvet  towel,  and  much  to  the  stu- 
dents surprise,  rolled  over  dead  from  no  injury,  but  from  shocK 
brought  on  by  mental  emotion. 

Pathology.- — The  pathology  of  shock  is  not  understood.  There 
are  about  fifteen  theories  to  explain  it,  but  only  two  will  claim  our 
attention.  These  come  nearer  explaining  it  than  any  yet  advanced, 
and  they  probably  act  together. 

i.  Yascula?'  Theory. — The  exponents  of  this  theory  claim  that  all 
the  symptoms  of  shock  are  due  to  the  variation  in  the  calibre  of  the 
blood  vessels,  which  is  regulated  by  the  vasomotor  nerves.  That 
the  stimuli  of  an  injury  inhibits  the  action  of  these  nerves  and  the 
vessels  become  widely  dilated.  Since  the  abdomen  contains  such 
an  abundant  vascular  supply,  the  dilation  in  that  region  causes  an 
accumulation  of  blood  there  (the  vessels,  when  in  a  dilated  condi- 
tion, being  able  to  hold  all  the  blood  in  the  body),  and  the  brain 
does  not  receive  a  sufficient  supply  of  blood  for  it  to  perform  its 
functions  and  shock  results.  The  symptoms  are  those  of  hemor- 
rhage and  in  fact,  it  is  intra- vascular  hemorrhage  into  the  abdomi- 
nal vessels.  This  theory  also  explains  the  mental  condition,  pale 
face  and  cold  skin. 

^2.  Nervotis  Theory. — The  advocates  of  this  theory  reason  from 
a  physiological  standpoint.     The  physiologist  tell  us  that  v^hen- 


86  PRINCIPLES    OF    SURGERY. 

ever  a  nerve  is  stimulated  it  performs  some  function,  and  on  re- 
peated stimulation  the  nerve  becomes  fatigued  and  fails  to  respond 
to  the  stimuli.  Xot\  they  claim  that  if  the  repetition  of  a  slight 
stimulus,  will  so  fatigue  a  nerve  as  to  inhibit  its  action,  one  great 
stimuli  will  produce  the  same  effect,  as  when  the  auditor}'  nerve  is 
stimulated  by  a  loud  sound  you  are  unable  to  hear  until  the  nerve 
has  rested.  So  it  is  in  shock.  The  stimulus  produced  by  the  in- 
jury so  fatigues  the  higher  nerve  centres  that  they  are  incapable 
of  perforning  their  functions,  and  the  person  is  in  a  state  of  col- 
lapse or  shock  until  the  centres  are  revived  by  rest. 

STMPTOiis. — The  face  is  so  changed  as  to  be  unrecognizable,  it 
has  a  pale,  cadaveric,  sickly,  white  appsarance,  eyes  sunken,  eye- 
lids droopbd,  nose  puckered,  the  skin  of  the  body  is  white,  cold, 
shrivelled  and  bathed  in  a  clammy  sweat.  The  mind  is  not  seri- 
ously affected,  there  is  no  delirium  or  unconsciousness,  but  he  acts 
slowly  and  doesn't  comprehend  his  position.  The  muscles  are  not 
paralyzed,  the  patient  being  able  but  not  inclined  to  move.  The 
respirations  are  feeble  and  shallow,  only  the  upper  portion  of  the 
lungs  being  used.  The  pulse  is  rapid  and  feeble  and  gives  a  flick- 
ering sensation  to  your  fingers.  The  temperature  is  sub-normal, 
which  gives  a  differential  diagnosis  from  a  chill,  as  in  a  chill  the 
other  symptoms  are  present,  but  the  temperature  is  above  normal. 

Termixatiox.  —  [f  reaction  occurs  the  symptoms  gradually  disap- 
pear. Color  comes  in  the  lips  and  cheeks,  the  fingernails  lose  their 
leaden  color,  warmth  returns,  the  patient  turns  in  the  bed  and 
vomits,  pulse  gets  stronger  and  more  regular,  respiration  fuller  and 
the  temperature  becomes  normal.  When  the  patient  shows  none 
of  the  signs  of  reaction,  and  the  symptoms  supervene  as  pictured 
in  the  first  of  this  lecture,  no  treatment  seems  to  do  any  good,  the 
patient  gradually  sinks  and  dies. 

Diagnosis. — Tbe  diagnosis  is  based  on  the  symptoms  and  the 
history.  It  may  be  confounded  with  hemorrhage,  but  the  treat- 
ment of  both  are  the  same. 

Prognosis, — The  prognosis  is  uncertain.  Patients  apparent)}''  at 
death's  door  may  recover,  whilst  those  about  whom  no  anxiety  has 
been  felt  suddenly  gets  worse  acd  dies. 

Treatment. — The  prophylactic  treatment  is  important.  Always 
before  commencing  a  serious  operation  put  your  patient  in  as  good 


PRINCIPLES    OF    SURGERY.  87 

condition  as  possible,  encouraoe  him  and  implant  in  his  mind  that 
he  will  recover,  but  be  sure  and  warn  the  parents  and  friends. 
Give  drugs  to  prevent  shock,  the  best  of  which  is  quinine;  if  you 
are  going  to  operate  at  one  o'clock  give  him  rive  grains  at  six 
o'clock  in  the  morning,  five  grains  at  nine  o'clock  aad  ten  grains 
at  twelve  o'clock.  If  the  heart  is  weak,  administer  one-tenth  to 
one-fifteenth  of  a  grain  of  strj^chnia  nitrate  an  hour  before  the 
operation,  alcohol  is  also  good,  but  never  give  it  just  before  the 
operation,  unless  by  the  rectum,  as  it  will  cause  vomiting  if  given 
by  the  stomach.  It  was  ths  old  custom  to  give  ^  grain  of 
morphia  to  1-100  grain  of  atropine,  but  quinine  is  now  prefer- 
able. Avoid  loss  of  blood,  time  and  heat.  The  modern  surgeons 
with  their  anaesthetics,  go  about  their  work  too  slow,  the  time  is 
notlost  so  much  from  slowness  of  operating,  but  because  the  proper 
preparations  have  not  been  made,  so  see  that  you  have  everything 
necessary  to  complete  the  operation  before  starting.  Avoid  loss 
of  blood  by  doing  quick  work,  by  being  careful  about  the  tourni- 
quet and  by  using  plenty  of  artery  forceps.  Avoid  loss  of  heat, 
don't  douche  the  patient  wath  cold  solutions  and  keep  off  draughts. 

If  shock  does  occur,  get  the  patient  to  bed,  don't  do  anything 
while  he  is  on  the  table.  Keep  him  absolutely  quiet,  exclude  rela- 
tions from  the  room  and  give  absolute  physiological  rest.  Get  the 
patient  warm,  wrap  a  hot  blanket  next  to  his  skin,  put  hot  bottles, 
flat  irons  or  bricks  to  his  feet,  stimulate  him  uith  morphia  1-6 
to  atropia  1-100,  give  one-tenth  grains  of  strychnia  and  re- 
peat in  a  half  an  hour,  give  whiskey  by  the  mouth  unless  the 
patient  is  nauseated,  then  give  it  per  rectum.  Hot  coffee  injected 
into  the  rectum  is  an  efficient  remedy,  it  gives  heat  as  well  as 
being  a  stimulant.  Lower  the  head  and  thus  let  blood  flow  by 
gravity  to  the  anemic  brain.  Practice  anto-transfusion,  this  is  ac- 
complished by  bandaging  the  legs  and  arms  and  thus  force  blood 
to  the  brain.  If  this  fails  practice  transfusion.  In  former  days 
blood  vvas  used  from  other  animals  and  forced  into  a  \ein,  this 
has  given  at\ay  to  the  normal  saline  solution  (one  teaspoonful  of 
salt  to  a  pint  of  ^ater);  boil  this,  and  when  it  falls  to  the  tem- 
perature of  the  body,  inject  directly  into  a  vein  or  into  the  sub- 
cutaneous tissue.     The  effect  is  sometimes  vvonderful. 

The  question  of  operating  dunng  shock  is  a  difficult  one  to  an- 
swer.    If  called  to  a  man  who  has  been  crushed  in  a  railroad  acci- 


PKINCIPLES    OF    SURGERY. 


dent  it  is  best  not  to  add  the  shock  of  an  operation  to  the  shock 
caused  by  the  injury,  for  you  are  almost  sure  to  kill  the  patient, 
bat  sometimes  the  shock  is  intensified  and  prolonged  by  the  pain, 
shock  succeeds  shock  and  you  had  better  operate. 


LECTURE  XXI. 


SEPTICEMIA. 

Septicemia  or  Sepsis  is  a  fever  produced  by  the  absorption  into 
the  system  of  the  products  of  fermentation  or  of  putrefaction.  The 
term  is  a  general  one  and  includes  the  three  following  conditions: 

1.  Aseptic  oe  Fermentation  Fever. — This  form  is  due  to  the 
absorption  into  the  system  of  the  products  of  aseptic  tissue  necrosis. 

Cause. — It  has  long  oeen  known  that  liquids  which  were  non- 
poisonous  when  injected  into  the  system  would  cause  fever;  normal 
saline  solutions  and  trypsin  will  do  it.  These  liquids,  when  injected 
into  the  system,  are  supposed  to  cause  the  fever  by  breaking  up 
the  white  blood  corpuscles  and  liberating  the  fibrin  ferment  which 
produces  fever.  So  in  this  form  of  fever  it  may  be  caused  by  using 
strong  antiseptic  solutions,  which  produce  necrosis  or  disintegra- 
tion of  the  tissue,  which  are  absorbed  or  by  closing  a  wound  before 
the  capillary  bleeding  stops,  thereby  forming  a  clot  which  disin- 
tegrates and  is  absorbed. 

Symptoms. — The  symptoms  are  plain.  After  performing  an 
opBration  and  using  strong  antiseptics,  in  about  twenty-four  hours 
you  will  find  your  patient  with  a  temperature  of  100  to  103  de- 
grees F.,  pulse  quick,  but  there  is  nothing  to  indicate  sickness, 
there  is  no  anorexia  or  prostration,  the  patient  says  he  feels  well 
and  may  not  stop  walking  around  his  room.  The  fever  lasts  from 
one  to  four  days  and  suddenly  subsides. 

Prognosis.  —Good. 

Treatment. — The  curative  treatment  is  "7^^7,"  for  the  patient 
will  be  well  in  forty-eight  hours,  but  by  proper  technique  you  can 


PRINCIPLES    OF    SURaERY,  89 

prevent  the  fever  and  thus  save  yourself  and  patient  the  anxiety. 
iSever  have  your  antiseptics  too  strong^;  obtain  thorough  haem- 
ostasis  before  closing  the  wound  and  you  will  not  be  bothered  with 
aseptic  fever. 

2.  Sapremia  or  Septic  Intoxication. — Sapremia  is  due  to  the 
absorption  into  the  s\^stein  of  the  products  of  putrefaction;  not  of 
the  germs,  but  of  their  products,  ^''Toxins  and  Ptomaines^ 

Cause. — The  cause  is  the  presence  in  the  wound  of  dead  tissue, 
which  has  become  infected  by  micro-organisnas  causing  it  to 
putrefy,  with  the  formation  of  toxins  and  ptomaines,  which  are 
absorbed  into  the  system  The  poison  is,  therefore,  formed  in  the 
wound,  and  does  not  come  from    ivithout. 

Symptoms. — In  about  forty-eight  hours  after  the  operation  there 
is  a  chill.  ITp  to  this  time  the  wound  does  well,  regardless  of  the 
piece  of  dead  tissue  it  contains,  this  is  beca'ise  it  takes  the  germs 
about  this  long  to  get  in  their  work.  The  chill  is  severe,  the  teeth 
chatter  and  the  bed  shakes;  fev^r  follows,  which  may  reach  LOi 
to  105  degrees  F.  The  symptoms  come  on  suddenly,  due  to  the 
sudden  introduction  of  poison  into  the  system,  and  they  reach 
their  maximum  intensity  from  the  first,  just  as  when  any  other 
alkaloid,  as  strychine  or  morphia,  is  introduced  into  the  system. 
The  fever  is  continuous;  pulse  rapid,  strong  and  bounding,  unless 
the  dose  of  the  poison  is  large,  when  it  is  rapid  and  feeble;  the 
digestive  system  is  horribly  upset,  anorexia,  vomiting  and  diar- 
rhoea supervenes  and  the  patient  refuses  all  food;  the  urine  is  con- 
centrated, of  a  high  color  and  loaded  with  urates;  on  standing  it 
has  a  mudd}^  appearance.  The  nervous  symptoms  commence  with 
the  chill;  there  is  depri^ssion,  terror,  irritability;  he  is  restless  and 
inquires  anxiously  about  himself;  in  a  short  while  he  becomes 
comatose,  the  pulse  growls  weaker  and  vveaker  and  gradually 
ceases.  Locally  the  wound  will  be  found  to  contain  a  piece  of 
dead  putrefying  tissue. 

Diagnosis. — The  diagnosis  is  based  on  the  symptoius  and  the 
fact  of  finding  dead  putrefying  tissue  in  the  wound,  which  the 
nose  readily  detects  on  examination. 

Prognosis. — This  depends  on  the  amount  of  the  poison  absorbed 
and  the  resisting  power  of  your  patient.  If  the  aose  is  sufficient 
to  kill  you  can  do  no  good,  but  if  the  first  dose  is  small  it  depends 


90  PRINCIPLES    OF    SURGERY, 

on  yoar  abilit}^  as  a  surgeon  and  the  situation  of  the  wound  v^hich, 
if  accessible  to  operative  interferences,  makes  the  prognosis  good. 

Treatment. — The  prophyhictic  treatment  consist  of  measures, 
which  prevent  the  decomposition  of  dead  tissue  when  it  is  left  in  a 
wound  through  necessity,  which  if  possible,  should  be  avoided, 
but  in  doing  a  Hysterectomy  you  are  compelled  to  leave  a  dead 
stump,  and  the  strictest  aseptic  precautions  must  be  taken  to  keep 
it  from  putrefying.  r>ry  the  surface,  dust  with  iodoform  and  dress 
with  plenty  of  antiseptic  gauze.  After  the  disease  has  developed, 
the  curative  treatment  consist  of  opening  the  wound,  removing  all 
dead  tissue  and  thoroughly  disenfecting  the  wounded  surfaces. 
Administer  tonics,  of  which  quinine  is  the  best  (three  grains,  three 
a  da\7^);  if  the  pulse  is  weak  give  one-tenth  grain  strychnia,  or  fif- 
teen drops  of  digitalis,  injected  under  the  skin,  but  the  latter  is  lia- 
ble to  produce  an  abscess,  give  whiskey  or  champagne  with  a  free 
hand,  even  until  the  face  flushes  and  it  can  be  detected  on  the 
breath. 

3.  Fkogkessive  Septicemia  or  Septic  Infection.  — Progressive 
septicemia  is  due  to  the  introduction  into  the  system  of  living 
pathogenic  micro-organisms.  The  poison  is  produced  outside  the 
body  and  conveyed  to  it  and  thus  makes  the  disease  not  very 
amenable  to  su.^gery. 

Cause. — The  cause  is  the  presence  in  the  blood  and  tissues  of 
germs,  which  multiply  and  produce  their  specific  poison.  How 
these  germs  get  into  the  body  and  how  they  act  is  not  known. 
The  disease  occurs  from  small  as  well  as  from  large  wounds.  The 
exact  nature  of  the  germ  is  not  known,  but  the  strejjtococr-.us  is 
usually  found  combined  with  other  germs. 

Symptoms.  —If  the  pathology  of  sapraeraia  is  remembered  you 
will  know  the  symptoms  of  septic  infe'^tion,  as  the  only  difference 
is,  in  sapremia  the  poison  is  produced  in  the  wound  and  in  this 
type  it  is  formed  outside  the  body.  The  symptoms  in  this  type 
comes  on  more  slowly  and  insidiously  and  the  disease  is  much  more 
grave.  The  wound  may  be  inflamed  and  angry  looking,  but  usu- 
ally there  is  no  marked  change:  the  chill  is  not  severe,  the  fever 
may  be  ele\:ated  to  106-107  degrees  F.,  or  it  may  be  sub-nor- 
mal, 97-98  degrees  F.,  and  in  this  case  the  temperature  never 
becomes  normal,  pulse  weak,  rapid,  and  as  the  disease  progresses 


PRINCIPLES    OP    SURGERY.  91 

becomes  more  and  more  irregular.  All  surgeons  agree  that  septi- 
cemia, with  a  good  pulse  and  high  temperature,  is  more  favorable 
to  the  patient  than  septicemia  "with  a  low  temperature.  The  face 
has  a  peculiar  look,  it  is  a  gasping  white,  pallid  and  drawn  with 
dark  circles  around  the  eyes,  there  is  indifference,  apathy, says  he 
feels  well,  soon  the  brain  breaks  down,  and  he  mutters  deliriously, 
the  skin  is  yellow,  cheeks  flushed,  anorexia,  nausea,  vomiting  and 
there  is  diarrhoea  in  half  the  cases,  the  urine  is  concentrated  and 
loaded  with  urates. 

Diagnosis, — It  is  differentiated  from  sapremia  by  not  finding 
dead  tissue  in  the  wound,  and  by  the  symptoms  coming  on 
slowly.  It  can  be  differentiated  from  Typhoid  fever  by  T3^phoid 
fever  having  a  prodromal  stage,  with  a  gradual  rise  of  tempera- 
ture. The  most  important  symptom  in  the  diagnosis  is  the  mental 
condition. 

Peognosis. — The  prognosis  depends  on  the  intensity  of  the  poison 
and  the  resisting  power  of  the  patient,  but  is  always  very  grave. 

Treatment, — All  we  can  do  is  to  assist  mother  nature,  the  poison 
is  being  generated  in  all  portions  of  the  body  and  cannot  be  bene- 
fited by  surgery.  The  prophlactic  treatment  consist  of  the  proper 
treatment  of  the  wound;  keep  io  clean  and  prevent  the  entrance 
of  the  germ  by  appropriate  antiseptic  applications.  The  curative 
treatment  consists  of  the  local  disinfection  of  the  wound,  and  as 
soon  as  the  disease  develops  give  perfect  drainage,  which  in  all 
probabilities  should  have  been  done  at  the  time  of  ttie  operation, 
but  v^  as  neglected.  Administer  tonics,  stimulants  and  highly 
nutritious  food.  If  possible  tne  new  serum  treatment  should  be 
tried. 


92  PRINCIPLES    OF    SURGERY, 


LECTURK  XXII. 


PYEMIA. 

Pyemia  is  caused  by  the  entrance  into  the  ci'^culation  of  pus  or 
the  products  of  pus,  and  is  characterized  by  recurrent  chills,  in- 
termittent fever  and  by  the  formation  of  metastatic  abscesses  on 
different  portions  of  the  bocl^^  This  disease  was  frequent  before 
the  advent  of  antiseptic  surgery,  but  is  almost  unknown  at  the 
present  day. 

Causes. — The  essential  cause  is  the  pus  microbe.  It  invariably 
occurs  after  suppuration;  this  has  been  proven  both  clinicallj"  and 
bacteriologically.  In  ev6ry  case  the  streptococcus  or  the  staphy- 
lococcus has  been  found  in  the  blood.  Some  observers  claim  that 
the  streptococcus  is  the  microbe  concerned,  others  that  it  is  the 
staphylococcus,  but  in  reality  both  are  concerned;  the  streptococ- 
cus being  found  more  abundant  in  the  acute  malignant  type  and 
the  staphylococcus  in  the  more  chronic  type  which  sometimes  yields 
to  treatment.  Koch  injected  pus  from  a  pyemic  abscess  into  an 
animal,  and  an  ordinary  suppurative  abscess  resulted,  pus  from 
this  was  injected  intravenously  causing  all  the  evidences  of  pye- 
mia. The  predisposing  causes  consist  In  the  localization  on  the 
body  of  a  suppurating  wound  near  a  vein.  The  disease  does  not 
occur  in  every  case  of  suppuration,  but  if  the  suppuration  is  deep, 
as  in  a  bone,  the  pus  is  more  liable  to  enter  the  circulation. 

Pathology. — We  have  a  wound  either  surgically  or  accidentally 
inflicted  which  becomes  infected  with  the  pus  germ.  The  germs 
proliferate,  causing  suppuration,  this  gradually  extends  through 
the  tissues  until  a  vein  is  reached;  the  tunica  adventitia  is  attacked 
and  finally  the  tunica  intin.  a  is  reached  causes  Phlebitis. 
The  tunica  intima  becomes  rough,  causing  the  white  corpuscles 
to  accumulate  on  it,  forming  a  thrombus,  which  extends  along 
the  vein  toward  the  heart.  This  is,  of  course  an  infected 
thrombus,  which  soon  disintegrates  and  emboli  are  carried  into  the 
circulation,  and  being  infected  they  cause  an  abscess  wherever  they 
lodge.     The   terras   thrombus,   embolus   and   infarction  may  need 


PRINCIPLES    OF    SURGERY.  93 

some  explanation.  A  thrombus  consist  in  the  formation  of  an 
intravascular  clot.  It  may  be  caused  by  any  irritant  applied  to  or 
neat  a  vessel,  v^hich  causes  roughening  of  the  tanica  intima  and 
corpuscles  accumulate,  causing  a  clot  (so  it  is  obvious  that  the 
fluidity  of  the  blood  depends  on  the  smooth  healthy  condition  of 
the  lining  of  the  vessels).  There  are  many  kinds  of  thrombi, 
Arterial,  Venous,  White  (when  composed  chiefly  of  white  and  third 
corpuscles).  Red  when  composed  chiefly  of  rea  corpuscles.  Parietal 
TV  hen  it  occupies  the  side  Ol  the  vessel  and  Obstructive  when  it 
entirely  closes  the  luraeu  of  tue  vessel.  A  thrombus,  if  not  in- 
fected, may  undergo  resolution,  but  if  infected  it  disintegrates  and 
an  embolus  results.  When  a  thrombus  grows  rapidly  and  reaches 
a  bifurcation  of  a  vein,  its  point  projects  into  the  vein  with  its  rapid 
flowing  blood,  and  the  end  is  broken  ofl"  aud  carried  into  the  circu- 
lation, and  this  constitutes  an  Embolus.  An  embolus  then  consist 
of  a  small  foreign  bodj^  in  the  blood.  It  goes  through  the  heart 
into  the  lungs,  here  it  usually  lodges  unless  it  is  small  enough  to 
pass  through  the  capillaries,  when  it  may  lodge  in  the  liver,  kidney 
or  spleen.  Fat  may  cause  an  embolus,  as  after  a  fractured  bone, 
but  in  each  case  the  result  is  the  same,  no  matter  where  it  ledges 
the  blood  is  cut  off  from  the  distant  tissues  supplied  by  the  plugged 
artery,  constituting  an  Infarction.  An  infarction  is  a  bloodless  or 
anemic  part  of  an  organ,  caused  oy  the  occlusion  of  the  nourishing 
vessel  by  an  embolus.  The  bloodless  part  is  triangular,  apex  to- 
ward the  plug,  base  looking  avvay  from  it.  As  soon  as  the  plug 
forms,  usually  some  capillary  ruptures  and  blood  is  poured  out  into 
the  tissues,  this  is  called  Hemorrhagic  infarction.  When  an  in- 
farction occurs  the  collateral  branches  do  their  best  to  supply  the 
part  and  in  some  organs  it  is  accomplished,  but  in  organs  w^ith  ter- 
minal arteries  like  the  kidney  and  spleen  there  is  no  means  of  estab- 
lishing the  collateral  circulation  and  necrosis  resulcs,  which  if  the 
embolus  be  aseptic  will  end  in  resolution,  but  if  it  be  infected  and 
therefore  the  seat  of  microbic  growth,  the  dead  tissue  will  be  at- 
tacked, causing  suppuration,  with  the  formation  of  metastatic  ab- 
scesses at  the  seat  of  localization  of  the  emboli  ami  also  in  other 
organs. 

Symptoms. — It   can   be  inferred  from  the  cause  that  the  disease 
does  not  rapidly  follow  the  infection  of  the  wound,  as  it  always 


94  PKINCIPLES    OF    SURGERY. 

follows  suppuration  and  time  must  be  given  for  the  germs  to  get  in 
their  jvork.  It  usually  occurs  from  nine  to  ten  days  after  the  in- 
fliction of  the  wound.  In  about  six  days  after  the  iufiiction  of  the 
wound  the  patient  becomes  restless,  anorexia  and  great  thirst  comes 
on;  when  the  wound  is  examined  you  will  not  find  a  laudible  or  so- 
called  healthy  pus,  but  there  is  a  sanious,  serous,  ill- smelling  fluid 
escaping,  the  part  is  swollen,  lips  of  wound  everted  and  the  granu- 
lations have  a  yellowish-gra3dsh  cast.  About  the  ninth  day  there 
will  be  a  severe  chill  which  will  last  about  an  hour,  skin  cold  and 
pallid,  but  the  thermometer  shows  a  temperature  of  103-104  degrees 
F.  The  fever  continues  four  or  five  hours  and  gradually  drops,  but 
never  leaves  entirely.  Then  comes  profuse  per  spiration  and  depres- 
sion. The  fever  is  not  intermittent,  but  remittent  in  character,  and 
the  chills  recur  at  irregular  intervals,  from  one  to  three  a  day.  The 
pulse  keeps  pace  with  the  temperature,  but  is  always  "weaker  and 
quicker  than  normal.  The  mental  faculties  are  not  affected,  there 
is  no  stupor,  unconsciousness,  nor  apathy,  the  patient  fully  recognizes 
his  position.  In  the  later  stages  the  great  exhaustion  and  prostra- 
tion brings  on  coma,  in  which  state  he  dies.  The  digestive  system 
is  not  seriously  disturbed,  there  is  loss  of  appetite  and  thirst,  but 
no  diarrhoea.  The  skin  is  peculiarlv  changed,  it  is  yellow,  simu- 
lating jaundice,  but  the  white  of  the  eyes  are  not  affected,  as  in 
jaundice.  In  a  short  while  abscesses  will  occur  in  various  portions 
of  the  body  and  the  symptoms  depend  on  where  it  is  located;  if  in 
the  lungs,  there  will  be  difficult  breathing  and  increased  dullness 
on  percussion;  in  the  liver  there  is  localized  peritonitis;  in  the 
spleen,  there  is  increase  in  size  of  the  organ  and  tenderness;  if  in  a 
joint,  the  symptoms  will  be  those  of  suppurative  arthritis. 

Morbid  Anatomy. — In  making  a  post-mortem  you  will  find  a 
wound  on  the  body  which  has  suppurated  and  close  by  you  will 
find  a  vein  v^ith  clotted  blood  in  it,  trace  the  clot  up  toward  the 
heart  and  its  apex  "will  be  found  projecting  into  a  bifurcation  of  the 
vein  and  its  end  broken  off.  The  lungs  have  a  number  of  abscesses 
in  it,  usually  at  the  periphery  beneath  the  pleura,  the  liver  and 
spleen  is  also  studded  with  abscesses  and  some  joint  filled  with  pus. 

Diagnosis. — The  diagnosis  is  based  on  the  history;  on  the  fact 
of  a  suppurating  wound,  a  sudden  chill,  with  repetition  of  same  at 
irregular  intervals,  variable  temperature,  prostration,  yellow  skin 
and  on  the  abscesses  on  various  portions  of  the  body. 


PRINCIPLES    OF    SURGERY.  95 

Prognosis. — The  prognosis  is  based  on  the  acuteness  and  inten- 
sity of  the  disease.  Acute  pyemia  usually  terminates  fatally  in 
live  or  six  days.  In  the  chronic  type,  where  the  fever  is  not  high 
and  abscesses  do  not  form,  the  prognosis  is  not  quite  so  grave. 

Tkeatment. — The  prophylactic  treatment  is  the  most  important 
and  on  this  I  would  lay  particular  stress,  as  we  can  prevent  the 
disease,  but  are  powerless  in  curing  it.  Prevent  suppuration  and 
you  prevent  pyemia,  and  to  prevent  suppuration  you  must  carry 
out  the  laws  of  asepsis,  which  have  been  laid  down  in  a  previous 
lecture.  If  the  disease  developes,  you  must  do  rigid  secondary 
sterilization;  curette  the  wound,  disinfect  with  a  strong  bi-chloride 
solution  or  chloride  of  zinc,  and  dress  antiseptically.  Some  sur- 
geons ligate  the  plugged  vein,  others  amputate,  but  it  is  best  to 
dissect  out  the  clot.  The  local  treatment  at  any  rate  can't  be  re- 
lied upon,  and  we  have  to  depend  on  constitutional  remedies,  tonics 
as  quinine,  gentian,  nux  vomica,  etc.;  stimulants  as  whiskey, 
which  must  be  given  in  unmeasured  quantities,  strychnine,  digi- 
talis and  good  nourishing  food. 

When  secondary  metastatic  abscesses  occur,  incise  freely,  irrigate 
and  drain.  When  suppuration  exist  in  any  cavity  it  should  be 
treated  as  laid  down  previously. 


LECTURE  XXIII. 


ERYSIPELAS. 

Erysipelas  is  an  acute  non-suppurating  inflammation  of  the  skin, 
characterized  by  a  crimson  blush  and  a  continued  fever. 

Cause. — This  disease  has  long  been  known,  but  only  recently 
has  it  been  proven  to  be  of  micro? >ic  origin.  It  has  long  been 
known  to  be  a  contagious  disease  and  with  the  discovery  of  its 
microbic  origin  many  experimenters  attempted  to  isolate  the  germ, 
but  not  until  1S83  was  it  isolated,  and  then  by  Febleisen.  It  is 
almost  identical  with  the  pus  germ,  ceing  slightly  larger  than  the 


96  PRINCIPLES    OF    SURGERY. 

streptococcus  pyogenes  and  a  little  larger  than  the  staphyloccccns. 
It  is  a  round  germ,  multiplies  by  tission  or  direct  segmentation  and 
forms  serpentine  chains.  It  grows  in  all  media,  the  most  favorable 
tempBrature  is  S5  degrees  F.,  and  there  is  no  growth  at  or  above 
104  degrees  F.  Owing  to  the  fact  that  the  germ  resembles  the 
pus  germ,  many  observers  claim  they  are  identical,  but  they  are 
distinct;  the  germ  of  erysipelas  does  not  produce  pus,  and  when 
pus  does  occur  in  an  erysipelatos  wound  it  is  because  it  has  also 
become  infected  with  the  pus  germ. 

Pathology  — When  erysipelas  starts,  it  is  due  to  the  entrance 
into  the  skin  of  the  streptococcus  erysipelatis,  and  as  the  unbroken 
skin  acts  as  a  barrier  to  the  germs,  there  ixust  be  some  breach  of 
continuity.  After  entering  through  an  ^''Infection  Atrium^''''  it 
localizes,  in  the  superficial  lymphatics  of  the  skin  and  produces  its 
effects.  The  germs  are  immovable,  but  they  proliferate  so  fast 
that  the  disease  rapidly  spreads  in  the  direction  of  and  also  against 
the  lymph  stream,  and  its  current  is  soon  stopped.  The  germ  is 
exceedingly  short  lived,  not  being  able  to  live  in  the  same  locality 
over  three  days  and  therefore  it  travels  from  one  point  to  an- 
other, like  a  tramp  in  quest  ol  food.  For  the  foregoing  reason, 
remedies  are  applied  to  prev^ent  their  migrating  and  thus  check- 
ing the  disease.  Some  observers  claim  that  when  localized  the 
leucocytes  kill  them;  while  others  say  that  on  account  of  being  so 
vigorous  they  soon  exhaust  tbe  food  at  the  point  of  localization 
and  then  they  move  to  better  supplied  parts  for  their  food. 

Symptoms. — General. — The  disease  has  a  sharp  period  of  incuba- 
tion, which  has  been  proven  by  observation  on  man  and  experi- 
ments on  animals  to  be  from  fifteen  to  sixty-one  hours.  After  this 
time  the  symptoms  are  ushered  in  by  a  chill,  which  is  sometimes 
replaced  in  children  by  convulsions,  there  accompanies  the  chill 
its  characteristic  phenomena,  pain  in  the  back,  pallid  skin  and 
sunken  eyes.  As  reaction  comes  on  the  fever  rises  to  102-108 
degrees  F.,  and  never  ceases  until  the  disease  is  eradicated,  it  is 
intermittant  but  continuous.  The  pulse  is  at  hrst  quickened,  but 
in  a  few  days  becomes  weak  from  the  effect  of  the  poison  on  the 
heart.  The  respirations  are  quick,  shallow  and  irregular.  The 
stomach  is  horribly  upset,  there  is  anorexia,  nausea,  vomiting  and 
diarrhoea. 


PRINCIPLES    OF    SURGERY.  97 

Local. — IVhen  you  find  a  patient  vAith  the  abov^e  symptoms,  if 
he  has  been  recently  operated  on,  examine  the  wound,  and  if  he 
has  been  accidentally  injured  he  will  direct  your  attention  to  the 
wound,  which  he  says,  is  tino;ling,  burning  and  smarting.  On 
examination  you  will  find  a  wound  with  a  crimson  blush,  which 
is  at  nrst  limited,  but  it  gradually  extends  to  neighboring  tissue. 
It  steadily  progresses  in  a  zigzag  manner,  the  division  between  it 
and  the  healthy  tissue  being  well  marked.  The  part  is  swollen, 
its  extent  depending  on  the  tissue  involved;  if  it  is  loose  it  will  be 
considerable,  if  tight  it  will  be  moderate.'  The  pain  is  severe,  and 
is  described  as  a  burning,  tingling,  scalding  pain.  The  tissues  feel 
tight  and  drawn.  When  the  disease  has  nearly  run  its  course 
there  will  be  desquamation.  The  wound  will  never  show  pus  un- 
less there  is  double  infection.  If  the  disease  be  watched  in  three 
days  it  will  berioticed  that  the  primary  focus  has  healed,  the  germs 
having  exhausted  the  food  at  that  point  and  a  new  S.eld  will  be 
invaded.  So  if  the  proliferation  of  the  germs  can  be  prevented 
you  can  cure  the  disease  in  three  days,  but  if  this  is  not  accom- 
plished the  disease  will  last  for  weeks. 

Yaeieties. — There  is  but  one  variety  and  but  one  germ,  but  the 
following  divisions  are  made  according  to  difference  in  degree  and 
clinical  features. 

Phlegmonous  Erysipelas. — This  is  a  type  of  the  disease  where 
we  have  the  co-existence  of  suppuration  and  erysipelas  at  the  same 
time  and  same  point,  due  to  mixed  infection.  There  are  all  the 
symptoms  described  befoie,  and  in  addition  there  is  pus.  This  is 
the  most  dangerous  type  of  erysipelas.  The  symptoms  of  erysipe- 
las are  overshadowed  by  those  of  suppuration  and  there  is  danger 
of  the  disease  terminating  in  Pyemia  or  Septicemia. 

Facial  Erysipelas. — The  medical  fraternity  speak  of  this  type 
as  Idiopathic  erysipelas,  which  means  the  disease  is  of  spontaneous 
origin,  occuring  without  an  '^infection  atrium.'^''  This  theory  is 
absurd,  a  relic  of  ignorance,  nothing  arises  spontaneously  and  the 
term  Idiopathic  is  now  being  obliterated  from  medical  literature. 
There  must  be  an  "/;2/ec2^/c»7i  atrium/''  through  w^hich  the  germ 
may  enter  or  else  there  will  be  no  symptoms  of  erysipelas.  Often 
on  close  examination  it  is  difficult  to  find  a  breach  in  the  skin,  but 
on  close  scrutiny  around  the  alae  of  the  nose  it  can  be  found  or  it 

7 


98  PRINCIPLES    OF    SURGERY. 

may  have  been  so  rainute  that  it  has  healed  before  the  onset  of 
the  disease  In  about  fifteen  to  sixty-one  hours  after  the  infection 
there  is  a  chill,  followed  b}^  fever.  The  skin  near  the  nose  will 
show  a  crimson  blush  and  there  is  nausea  and  anorexia.  The  dis- 
ease gradually  extends  to  the  cheek,  then  to  the  soft  tissues  around 
the  eye,  which  may  become  so  swollen  as  to  close  the  lids;  it  then 
crosses  over  the  nose  to  the  other  eye  p.nd  cheek,  then  it  ruos  up  on 
the  forehead  along  the  hair  to  the  back  of  the  ear,  finally  coales- 
cing behind  the  head.  Strange  to  say  it  never  attacks  the  chin  or 
the  posterior  surface  of  the  neck.  This  type  of  the  disease  is  usu- 
ally self -limited  and  ceases  in  about  ten  days,  causing  little  anxiety, 
although  the  disease  may  become  very  serious  by  the  germ  extend- 
ing to  the  brain  through  the  lymphatics,  causing  meningitis.  This 
complication  can  be  readily  recognized  by  the  fever  being  accom- 
panied by  delirium  ^hich  does  abate  with  the  disease. 

Erysipelas  Neonatoedm. — This  type  of  the  disease  was  formerly 
very  common,  but  is  rarely  seen  now.  It  attacks  the  umbilical 
cord  of  new  born  children  and  was  of  frequent  occurrence  in  ''■lying 
in  hospitals'"  before  the  days  of  antisepsis  and  asepsis.  Soon 
after  birth  there  appears  a  crimson  blush  at  the  umbilicus,  which 
gradually  extends  around  the  body,  there  is  a  chill  or  convulsion 
and.  bullae  form.     This  type  usually  ends  fatally. 

Erysipelas  of  Mucous  Membranes. — This  type  attacks  mucous 
surfaces  as  the  mouth,  tonsils,  rectum  or  vagina.  The  symptoms 
are  the  same  as  delineated  above,  except  on  account  of  the  natural 
crimson  hue  of  mucous  membranes  this  symptom  can't  be  observed. 
]^(either  does  it  show  on  negroes  when  attacking  the  skin,  and  we 
diagnose  by  general  symptoms. 

Diagnosis. — Tne  diagnosis  in  well  marked  cases  is  plain.  The 
fact  of  the  patient  having  a  wound  or  an  'Hnfection  atrium^'''  the 
chill,  fever,  crimson  blush  around  the  wound,  which  extends  in  a 
zigzag  manner,  swelling,  heat  and  a  burning,  scalding  pain.  It  is 
different iated  from  Erythema  by  finding  healthy  tissue  between 
the  red  discoloration  of  the  skin,  whereas  in  erysipelas  the  dis- 
coloration is  uniform;  from  Lymphangitis,  by  its  attacking  the 
superlicial  lymphatics,  whereas  lymphangitis  attacks  the  deep 
lymphatica,  but  in  reality  it  is  nothing  but  a  superficial  lymphan- 
gitis.    Phlebitis  can  be  differentiated  from  it  by  the  red  color  fol- 


PRINCIPLES    OP    SURGERY.  99 

lowing  the  anatomical  course  of  the  veins  and  the  veins  in  phlebitis 
feel  lii^e  cordo.  Phlegmonous  inflammation  can  be  differentiated 
by  its  starting  deep  down  in  the  tissues  and  approaching  the  sur- 
face, while  erysipelas  starts  superficially  and  penetrates  deepl3^ 

Prognosis. — The  prognosis  is  good  in  uncomplicated  erysipelas, 
but  very  grave  when  there  are  complications,  such  as  suppuration, 
pyemia  or  septicemia. 

Treatment. — Twenty  years  ago  erj'^sipelas  attacked  the  wounds 
in  half  the  operations,  but  since  the  advent  of  aseptic  surgery  the 
disease  has  been  banished,  and  when  it  does  occur  it  is  due  to 
bungling  and  dirty  work.  Treat  wounds  and  make  \^  ounds  by 
the  laws  laid  down  previously,  and  you  will  never  have  erysipelas. 
If  the  disease  does  develop,  the  treatment  must  be  both  local  and 
constitutional.  The  local  applications  are  numerous,  almost  every 
drug  in  the  pharmacopeia  has  had  their  endorser,  which  shows 
there  is  no  specific,  and  as  erysipelas  is  a  self-limiting  disease  you 
can't  put  much  dependence  in  drugs.  Those  mostly  used  at  pres- 
ent are  Iodine,  Nitrate  of  Silver,  injections  of  Carbolic  Acid,  and 
Bi-chloride  Mercury,  Oxide  Zinc,  Ichthyol,  hot  and  cold  applications 
and  numerous  others.  Take  my  advice  and  leave  these  drugs  alone 
and  practice  the  following:  Eender  the  part  clean  with  green  soap, 
wash  then  with  alcohol,  and  then  use  a  bi-chloride  solution  to  kill 
any  pus  germs  that  may  be  lurking  around  and  thus  prevent  com- 
plications, IN'ow  apply  a  compress  saturated  with  a  not  antiseptic 
solution;  apply  it  this  way,  take  a  thick  wad  of  cotton  and  some 
feeble  antiseptic  solution,  such  as  1-1000  bi-chloride,  1-203  carbolic 
acid  or  acetate  of  aluminum  and  place  it  in  a  pan  and  heat  it  con- 
tinually over  an  alcohol  lamp,  \^  ring  out  the  cotton  pad  and  apply 
to  the  part;  repeat  every  hour.  The  object  of  this  treatment  is 
thorough  cleanliness  to  prevent  complications  by  the  pus  germ, 
heat  lessens  pain  and  you  exterminate  the  germs  of  erysipelas  as 
it  can't  stand  a  ten  perature  over  104:  degrees  F.,  and  the  solution 
must  be  up  to  110-120  degrees  F. ;  the  temperature  of  the  skin  is 
thus  raised  above  10-1  degrees  F.  and  the  germs  are  killed.  jSever 
use  salves  or  caustics.  Constitutional  remedies  must  be  given  to 
preserve  the  strength.  Give  stimulants  in  large  quantities,  good 
easily  digested  food  and  tonics  as  quinine  and  iron.  Never  use  the 
coal  tar   products,  they  are  too  depressing.      Give  opium  for    the 


100  PRINCIPLES    OF    SURGERY. 

pain,    of  which    Dover's  powder  is   the   best.     If  complications 
occur  treat  them  on  general  principles. 

Curative  Power  or  Erysipelas  A:NrD  Its  Therapeutical  Use. — 
It  was  observed  many  years  ago  that  patients  suffering  from  can- 
cer which  resisted  all  remedies,  when  attacked  by  erysipelas  were 
cured  cf  the  cancer,  that  sarcoma  of  bones  was  cured  by  an  attack 
of  erysipelas,  etc.  A  German  physician  observed  in  the  case  of 
his  son,  VNho  was  nearly  dead  from  diphtheria,  that  after  he  was 
attacked  b}^  erysipelas  of  the  mouth  in  the  course  of  the  disease, 
that  the  membranes  were  thrown  off  and  the  son  recovered.  And 
so  it  has  been  found  that  the  germ  of  erj^sipelas  is  antagonistic  to  the 
germs  of  many  diseases.  Many  patients  have  been  killed  by  inject- 
ing the  germs  of  erysipelas  into  them  for  the  cure  of  cancer,  but 
now  we  are  using  their  toxins  instead  of  the  germs,  and  the  treat- 
ment is  not  so  dangerous.  Dr.  Kohle,  an  ardent  supporter  of  the 
antagonism  of  this  germ  to  the  germ  of  cancer,  reports  two  or  three 
hundred  cases  of  cancer,  which  had  been  given  up  as  past  the  pale  of 
surgery,  which  he  treated  successfully  b}''  inoculating  theiE  with 
the  mixed  toxins  of  the  Streptococcus  erysipelatis  and  Bacillus  pro- 
digiosus.  Other  doctors,  viz. :  Senn,  of  Chicago,  and  Keen,  of 
Philadelphia,  have  tried  Dr.  Kohle's  treatment  without  success. 
In  spite  of  the  results  attained,  I  believe  we  are  on  the  verge  of  a 
great  discovery  for  the  cure  of  this  disease,  as  well  as  for  diph- 
theria. The  toxins,  when  injected  into  man,  do  not  produce  ery- 
sipelas, but  their  chemical  properties  has  a  deleterious  effect  on  the 
germs  cf  cancer  and  diphtheria. 


PRINCIPLES    OF    SURGERY.  101 


LECTURE  XXIV. 


TETAXUS— SCURVY. 

Tetanus  or  Lockjaw  is  an  infectious  disease,  in  which  the  srerm 
that  produces  it  acts  on  the  Cerebro-spinal  nervous  system,  pro- 
ducing rigidity  and  spasms  of  definite  groups  of  muscles.  This 
disease  has  long  been  known  and  was  supposed  to  be  due  to  ner- 
vous reflex  irritability^  from  a  wound  to  the  centers.  This  theory 
is  still  held  by  some,  but  has  been  abandoned  by  the  better  in- 
formed surgecns.  It  is  now  known  to  be  an  infectious  disease, 
due  to  a  specific  microbe;  the  following  observations  should  con- 
vince the  most  skeptical:  A  bullock  which  had  died  from  lockjaw, 
"v^  as  eaten  by  a  lot  of  slaves  and  every  one  of  them  died  from  the 
disease,  showing  that  there  was  some  specific  poison  in  tha  meat. 
A  horse,  having  died  from  lockjaw  in  a  certain  stall  of  a  stable, 
vs^hich  was  afterwards  used  by  a  bitch  in  having  puppies,  seven  of 
the  pups  died  from  the  disease,  and  the  children  that  played  with 
them  also  contracted  the  disease.  Recently  it  has  been  recorded 
where  a  woman,  while  walking  across  a  barn  yard,  fell  and  wounded 
her  elbow,  she  contracted  lockjaw  and  died;  on  investigation  it 
was  found  that  not  long  before  a  horse  had  died  of  tetanus  in  the 
yard,  and  the  germs  were  planted  in  the  soil  and  in  this  way  she 
contracted  the  disease. 

Cause. — The  disease  is  caused  by  a  specific  microbe.  Tt  is  due 
to  the  many  experiments  of  Xicolaier  who,  in  1S84,  published  his 
discovery  of  the  germ.  He  proved  that  it  is  a  bacillus,  rod-shaped 
and  is  peculiar  in  having  a  spore  near  one  end,  which  gave  it  the 
appearance  of  a  drum  stick.  It  is  an  anaerobic  germ,  and  there- 
fore requires  the  exclusion  of  oxygen  for  its  growth,  and  this  is  an 
important  point  to  remember  in  the  treatment.  Great  difficulty 
has  been  experienced  in  its  cultivation;  it  gro^s  in  sterilized  blood 
serum  and  in  gelatin  after  the  addition  of  grape  sugar;  it  groves 
best  at  80  degrees  F.,  but  will  also  grow  above  and  below  this;  it 
is  the  most  resisting  germ  we  have  to  deal  with,  but  is  killed  after 
ten  minutes  boiling  or  steaming;  it  multiplies  by  spore  formation 


102  PRINCIPLES    OF    SURGERY. 

and  grows  in  man  only  when  inoculated  deep  enough  to  be  out  of 
contact  of  oxygen.  Tnis  germ  is  exceedingly  common  and  widely 
distributed,  being  found  in  manure,  street  dust,  garden  soil,  old 
mortar  and  bricks.  Owing  to  the  fact  of  its  beinor  an  anaerobic 
germ,  infection  is  rare,  except  when  a  deep  soil  is  upturned.  There 
is  on  record  a  very  peculiar  coincident.  Daring  an  earthquake 
ttiere  was  demolished  two  old  stoce  churches,  which  were  only  a 
tew  miles  apart.  In  each  there  were  two  or  three  hundred  wor- 
shippers, and  a  great  man}?-  were  injured.  In  one  case  seventy 
were  injured,  out  of  which  forty  died  of  lockjaw;  wbile  one  hun- 
dred and  fifty  w^ere  injured  in  the  other  case  none  contracted  the 
disease.  On  exarcination  the  bacillus  of  tetanus  was  found  in  the 
former  case  and  none  were  found  in  the  latter.  The  germ  can't 
enter  the  body  unless  there  be  an  ''infection  atriiwi,''''  there  is  no 
such  thing  as  idiopathic  tetanus.  The  germ  proliferates  and 
grows,  but  is  not  disseminated  through  the  body,  it  localizes  and 
is  never  found  in  the  blood.  The  symptoms  arise  from  the  absorp- 
tion into  the  sj^stem  of  the  toxins  or  ptomaines  produced  by  the 
germs.  Their  toxins  are  described  as  being  of  four  kind,  and 
different  sj'^mptoms  are  given  for  each,  but  this  is  too  theoretical 
to  indulge  in.  The  germ  may  enter  through  any  abrasion,  but 
usually  gains  admittance  through  wounds  on  the  feet  or  hands,  as 
these  members  are  more  liable  to  both  injury  and  infection.  It 
occurs  in  men  oftener  than  in  women,  oa  account  of  their  being 
more  liable  to  injury.  It  is  most  frequently  seen  in  jockej^s,  stable 
boys,  gardeners  and  street  cleaners,  who  by  their  occupation,  are 
more  exposed  to  tbe  germ.  The  wound  must  be  a  deep  punctured 
wound,  so  as  to  exclude  oxygen. 

Cli^jical  Varieties. — 1.  Acute,  This  develops  only  a  few  hours 
after  tbe  infliction  of  the  wound.  The  symptoms  are  severe  and 
intense,  ending  in  great  prostration  and  death.  2.  Chronic. 
This  comes  on  in  two  or  three  weeks  after  infection.  Tbe  symp- 
toms are  less  severe  and  recovery  may  occur.  This  difference  in 
type  is  either  due  to  the  dilTerence  in  the  virulency  of  the  germ  or 
to  tne  resisting  powder  of  the  patient. 

SvMi'ToMs. — Suppose  a  man  working  in  a  garden  sticks  the  prong 
of  a  rake  in  his  foot,  or  in  walking  across  a  barn  yard  sticks  a  nail 
in  his  foot.     In  two  or  three  weeks  he  becomes  indisposed,  cross, 


PRINCIPLES    OF    SURGERY.  103 

irritable,  irnder  the  weather,  despondent,  forbodes  evil  and  anx- 
iously ponders  over  his  condition.  lie  complains  of  chilliness  and 
slio'ht  stirfness  about  his  neck,  he  tries  to  eat  and  accidentally  dis- 
covers that  he  can't  open  his  mouth  sufjiciently  to  drink  or  to  re- 
ceive his  food.  There  is  no  pain  or  swelling,  nothing  abnormal  is 
found  except  the  inabiJity  to  open  his  mouth,  due  to  rigidity  of 
the  muscles  of  mastication.  He  becomes  alarmed  and  sends  for 
the  doctor  or  treats  it  lighty  and  irons  his  neck  for  ^'- Crick'"'  in 
the  muscles.  Soon,  however,  there  is  pain,  the  stiffness  of  the 
neck  increases  and  the  jaws  are  firmly  locked  ;  the  muscles  of  the 
back  now  become  involved,  they  contract  and  as  a  result  the  head 
is  thrown  back,  the  spiae  is  arched  and  the  body  assumes  the  posi- 
tion known  as  Opisthotonos,  the  head  and  heels  being  the  only 
parts  touching  the  bed.  The  muscles  of  the  thoi'ax  next  con- 
tract, then  the  diaphragm,  which  results  in  obstruction  to  respira- 
tion. The  face  has  a  peculiar  look,  the  muscles  are  contracted,  no 
expression  and  the  risorious  muscle  contracting,  produces  the  ghastly 
grin  called  '^ Bisiis  Sardonicus.''^  There  is  pain  through  the  whole 
body  and  the  slightest  noise  or  touch  or  even  a  draught  of  air 
throws  him  into  a  convulsion.  He  has  no  control  over  his  urine, 
can'c  eat  or  take  any  nourishment,  the  pulse  is  quick  and  weak, 
the  temperature  may  be  up  to  103-108  degrees  F.,  respirations 
shallow  and  labored,  and  he  finally  dies  from  the  excrucinting 
pain,  exhaustion  and  starvation.  Chronic  tetanus  only  differs  from 
the  above  typical  case,  in  not  being  as  intense,  the  jaws  not  so 
firmly  locked,  slight  stiffness  about  neck  and  there  are  no  convul- 
sions. 

Diagnosis. — The  positive  diagnosis  is  easy.  The  fact  of  there 
being  a  wound  which  was  inflicted  by  a  nail  or  a  rake  which  is 
contaminated  by  the  germs  of  tetanus.  On  the  symptoms,  jaws 
locked,  muscles  contracted,  etc.  The  differential  diagnosis  is  more 
complicated.  It  may  be  confounded  with  hysteria,  especially  in 
young  girls,  where  the  jaws  are  locked,  but  you  differentiate  it  by 
the  jaws  not  being  firmly  locked,  no  fever  and  b}^  there  being  no 
marked  change  in  the  pulse.  It  can  be  differentiated  from  strych- 
nia poison  by  the  history,  and  in  strychnia  poison  the  convulsions 
come  on  as  soon  as  the  drug  is  taken,  in  tetanus  they  come  on  from 
day  to  day,  and  in  strychnia  poison  the  jaws  are  rarely  involved. 


104  PRINCIPLES    OF    SURGERY. 

It  can  be  differentiated  from  hydrophobia  by  the  history,  the  per- 
son having  been  bitten  by  a  rabid  animal.  In  tetanus  the  period 
of  inoculation  is  much  shorter  and  the  muscles  of  mastication  are 
effected,  vphereas  in  hydrophobia  the  muscles  of  deglutition  are  in- 
Yolv^ed. 

Pkogxgsis.' — Seventy-five  per  cent,  of  all  cases  die.  One  writer 
says  that  all  cases  that  resist  the  disease  for  five  days  get  well. 
In  the  acute  form  all  die,  while  in  the  chronic  typa  a  great  many 
recover. 

Treatment. — Prophylactic. — This  treatment  is  of  the  greatest 
importance.  Twenty  years  ago  half  the  operations  were  followed 
by  lockjaw;  surgeons  of  repute  lost  as  many  patients  from  it  as 
those  of  non-repute,  and  patients  were  always  informed  that  teta- 
nus v\as  one  of  the  dangers  of  the  operation.  To-day  surgeons 
never  fear  lockjaw  if  they  do  aseptic  surgery.  If  a  patient  comes 
to  you  with  a  dirty  punctured  wound,  it  is  your  duty  to  sterilize  it 
to  its  utmost  depths.  Don't  depend  on  sticking  a  syringe  in  the 
hole  and  throwing  antiseptic  solutions  into  the  wound,  but  split 
the  part  open,  remove  every  particle  of  dirt,  disinfect  it  with  bi- 
chloride mercury  1-2000,  pack  with  antiseptic  gauze  and  allow 
access  of  oxygen.  This  procedure  looks  cruel,  but  it  is  your  duty  ; 
tetanus  is  still  a  common  trouble,  and  if  in  every  twenty  punctured 
wounds  you  prevent  one  case  by  the  operation,  you  save  one  life 
arid  give  the  others  a  wound  which  may  be  a  little  longer  healing. 

Curative.  —  When  a  case  develops,  and  in  the  acute  form,  you 
can  do  nothing  but  administer  an  anodyne  and  give  him  aix  easy 
death.  If  it  is  in  the  chronic  form,  give  chloroform  for  the  pain 
(this  is  the  best  drug  in  both  forms),  as  soon  as  the  convulsions 
commence,  give  it  continually,  if  you  are  compelled  to  leave  get 
your  assistant  to  administer  it.  Don't  give  it  to  the  extent  of  com. 
plete  anaesthesia,  lut  give  it  like  you  v^  ould  in  an  obstretric  case. 
Give  morphia  and  atropine,  which  acts  well  in  conjunction  with 
the  chloroform  {\-\  grain  morphia  to  1-150  grains  of  atropia  and 
repeat  in  three  hours).  Give  b}^  rectum  30  grains  each  of  chloral 
hydrate  and  bromide  of  potash.  Give  good  nourishing  food  In 
mild  cases,  pull  out  a  tooth  and  feed  through  the  hcle  or  introduce 
an  elastic  catheter  through  the  nose,  through  the  oesophagus  into 
the  stomach  and  give  through  this  one  pint  of  egg  nog  every  four 


PRINCIPLES    OF    SURGERY.  105 

hours.  In  some  cases  neither  of  the  above  will  do,  then  resort  to 
enemas.  Most  doctors  have  no  faith  in  enemas,  but  a  patient  can 
be  kept  alive  and  in  fact  will  fatten  on  nutrient  enemas  if  properly 
administered.  In  giving  an  enema,  remember  that  the  rectum 
can't  digest  food,  but  it  v^ill  absorb  it,  if  it  be  predigested.  Don't 
give  over  three  enemas  in  the  twenty-four  hours,  or  you  will  irritate 
the  rectum  and  it  wont  retain  ihe  food.  "Wash  out  the  rectum 
once  in  twenty-four  yours  to  remove  the  food  which  has  not  been 
absorbed  and  will  ferment  if  allowed  to  remain.  Don't  give  over 
four  to  six  ounces  at  a  time,  and  have  it  about  the  temperature  of 
the  blood.  Focd  material  can  be  used  to  suit  the  patient's  purse 
and  the  fancy  of  the  doctor,  but  any  predigested  nutritious  food 
will  do.  Xever  put  pure  milk  into  the  rectum,  as  it  will  not  be 
absorbed,  predigest  it  with  pepsin.  Yalentine's  meat  juice  is  good. 
The  most  satisfactory  enema  I  have  ever  used  is  as  follows: 

R 

Whiskey  ^ss  (5-  ounce) 

Yelk  of  egg  No.  1 

Valentine's  Meat  Juice  ^ss  {i  ounce) 

Peptonized  Milk  ,f  iv  (4  ounces) 

Beat  the  yolk,  add  the  whiskey  and  beat  until  the  egg  is  cooked, 
add  the  meat  juice  and  milk  hot,  put  in  a  tun: bier  until  it  is  the 
temperature  of  the  blood,  then  with  an  ordinary  syringe  with  a 
catheter  attached  throw  it  into  the  rectum.  This  is  about  all  you 
can  do.  It  is  absolutely  necessary  to  have  a  good  nurse,  make  her 
wear  rubber  shoes,  darken  the  room,  stop  all  talking  and  noise  and 
some  cases  will  recover.  Try  the  new  antitoxin  that  has  just  come 
out. 

SCURVY. — This  disease  is  not  due  to  a  germ.  It  is  a  constitu- 
tional disease  caused  by  improper  diet  or  to  bad  bygenic  surround- 
ings. It  is  characterized  by  interference  with  nutrition  and  by 
hemorrhages  in  various  portions  of  the  body.  The  disease  was  un- 
known before  the  fifteenth  century,  but  with  the  discovery  of 
America,  with  the  extension  of  navigation,  with  the  advent  of  the 
spirit  of  venture  into  the  Artie  region  the  disease  developed  and 
has  raged  in  epidemic  form  very  often  since.  Northern  writers, 
in  dealing  with  this  subject,  seem  to  take  a  peculiar  delight  in  men- 
tioning the  epidemic  at  Hendersonville  as  an  example  of  privation, 


106  PRINCIPLES    OF    SURGERY. 

neglect  and  cruelty.  This  comes  with  very  poor  grace  from  a 
class  of  people  vsho  refused  to  send  palliative  drugs  and  food,  and 
v(  ho  would  not  allow  their  own  surgeons  to  administer  help  to  their 
suffering  brothers,  when  both  of  these  privileges  were  extended  to 
them. 

Cause. — It  is  caused  by  the  food  not  containing  a  sufficient 
amount  of  vegetable  acids,  by  eating  continually  nothing  but  canned 
goods  and  drinking  impure  water,  etc.  People  who  live  in  pens, 
prison's  and  in  ships,  where  the  bilge  water  is  foul  are  those  who 
contract  the  disease. 

Symptoms. — The  disease  comos  on  slowly.  A  sailor  who  has 
been  active,  strong  and  robust  aboard  some  ship,  becomes  sloathful, 
drowsy,  depressed,  loses  strength,  pain  in  his  back,  skin  yellow 
and  sallow,  finally  becoming  scaly  and  cracked,  his  gums  become 
tender,  oedematous,  blue  ]n  color  and  bleeds  easily;  the  skin  then 
becomes  spotted,  petechial  spots  appear  at  the  base  of  the  hair, 
tbese  desquimates  and  finally  ulcerates;  the  heart  is  weak,  he  be- 
comes emaciated  and  dies  from  prostration. 

Diagnosis. — The  diagnosis  is  based  on  the  history  and  syna  p- 
toms.  It  can  be  told  from  Purpura  Hemorrhagica  by  the  cach- 
exia, persistent  pains  and  fetid  breath,  and  from  Anemia  by  the 
microscope. 

Pkognosis.-— The  prognosis  depends  on  the  stage  in  which  you 
see  the  patient.  If  you  see  him  in  the  early  stage,  it  is  good,  but 
if  you  do  not  see  him  until  the  later  stages  it  is  exceedingly  grave. 

Treatment. — The  prophylactic  treatment  consists  in  having 
proper  food  and  proper  hygenic  surroundings.  K  a  ship  is  going 
off  on  a  long  voyage,  it  should  be  well  ventilated,  stock  it  with 
live  stock,  fresh  food  and  pure  water.  Amongst  the  most  valuable 
antiscorbutics  are:  Eggs,  milk,  onions,  potatoes,  turnips,  cran- 
berries, limes,  lemons  and  sourkraut.  If  the  disease  developes  the 
curative  treatment  consists  almost  exclusively  of  dietetics;  give  the 
above-mentioned  articles  of  diet  and  also  give  medicines  as  tonics. 
Use  antiseptics  on  the  ulcers  to  prevent  gangrene. 


PRINCIPLES    OF    SURGERY.  107 


LKCTURK  XXV. 


WOUNDS. 

A  wound  may  be  defined  as  a  sudden  solution  of  the  continuity 
of  soft  tissues.  This  definition  excludes  fracturt^s,  although  a  frac- 
ture is  a  wound,  but  not  of  the  soft  tissues,  and  will  be  discussed 
elsewhere.  An  ulcer,  technically,  is  not  a  wound,  because  it  is 
produced  by  slow  disintegration  aud  not  by  sudden  solution  of  the 
tissues.  The  term  "  Woioirr^  applies  to  some  external  mechanical 
force  or  violence  which  rents  tbe  tissues.  The  frequency  which 
wounds  occur,  and  the  number  of  times  you  will  be  called  to  treat 
them,  show  their  importance. 

Varieties. — Wounds  are  divided  into  accidental,  operative,  open, 
subcutaneous,  aseptic  and  septic.  Accidental  wounds  are  wounds 
inflicted  accidentally  by  some  unexpected  violence.  Operative 
wounds  are  wounds  made  after  careful  consideration  to  relieve  pain 
or  to  save  life.  Open  wounds  are  wounds  in  which  there  is  a 
breach  in  the  skin  or  mucous  membranes,  and  is  exposed  to  the 
air.  Subcutaneous  wounds  involve  the  subcutaneous  tissues,  the 
skin  or  mucous  membrane  remaining  intact,  as  the  rupture  of  a 
muscle  or  tendon,  and  not  being  in  contact  with  the  air  they  are 
not  infected  by  germs.  Aseptic  v^ounds  do  not  become  inflamed 
on  account  of  the  pyogenic  germs  being  excluded  when  the  w^ound 
was  inflicted,  by  nature's  resisting  the  action  of  the  germs  or  by 
the  use  of  antisepsis  and  asepsis  which  prevents  inflammation. 
Septic  wounds  are  wouds  which,  at  the  time  of  infliction  or  after- 
wards, have  become  infected  by  pyogenic  germs  which  produce 
inflammation. 

Cause. — The  causes  are  too  numerous  to  mention.  But  all 
wounds  are  due  to  some  sudden  application  of  mechanical  force. 
It  may  be  by  a  knife,  brick  bat,  club,  pistol  ball,  or  an  arrow  or  any 
mechanical  force. 

Pathology. — The  pathology  is  the  same,  no  matter  what  the 
location  or  cause  of  the  wound,  and  the  process  of  healing  is  also 
the  same  viz.:   Surgical  regeneration.      In  ever37^  wound  there    is 


108  PRINCIPLES    OF    SURGERY. 

death  of  cells  in  proportion  to  the  cause;  in  a  wound  made  by  a 
sharp  i-:nife,  the  death  is  limited  to  the  cells  traversed  by  the  sharp 
edge,  whereas  a  wound  made  by  a  brick  bat,  the  death  of  the  cells 
is  much  more  extensive;  but  in  each  case  the  patholooy  is  the 
same,  there  is  death  of  cells  which  are  replaced  by  granulation, 
vascularization,  cicatrization  and  epidermization. 

Symptoms. — The  symptoms  are  the  same  in  all  wounds,  viz.: 
Pain,  Hemorrhage,  Gaping  and  Impairment  of  function.  Every 
wound  is  accompanied  by  pain,  the  character  and  intensity  v^arying 
with  the  cause,  anatomical  location  and  the  susceptibility  of  the 
individual.  A  wound  made  with  a  sharp  knife  imparts  to  ihe  brain 
a  sharp,  stinging  pain,  which  soon  becomes  a  smarting  pain,  and 
may  last  for  hours  and  then  subside.  A  wound  made  by  a  dull, 
bruising  instrument,  causes  no  pain  immediateh''  after  infliction, 
but  it  comes  on  slowly,  gradually  growing  worse.  Some  tissues 
give  more  pain  thaa  others  when  wounded;  as  a  wound  of  the 
sensitive  finger  compared  to  a  wound  on  the  back.  Jn  soixe  indi- 
viduals tbe  pain  from  the  same  wound  i«  more  acute  than  in  others, 
and  in  the  same  individual  under  different  circumstances,  a  nervous, 
debilitated  person  suffers  more  pain  under  the  same  injury  than  a 
robust,  phlegmatic  person,  and  the  remark  will  be  made  that  he  had 
more  ner^e,  but  it  is  just  the  reverse.  The  same  persons  will  suffer 
more  on  different  occasions,  as  a  man  cut  while  his  stomach  is  full 
and  he  is  well  stimulated  will  not  suffer  much  pain,  but  the  next 
day,  if  he  is  debilitated,  he  will  suffer  considerabl}^.  Hemorrhage 
is  an  invariable  symptom  and  varies  according  to  the  force  or  in- 
strument causing  the  wound  and  the  constitution  of  the  individual. 
If  the  w^ound  was  made  by  a  knife,  the  hemorrhage  occurs  instan- 
taneously, but  if  made  by  a  cog  wheel,  it  does  not  come  on  for 
some  time,  for  the  vessels  are  ground  in  two,  the  ends  are  lacerated 
and  fringed  and  often  the  lumen  of  the  vessel  closed,  but  in  a  icnife 
cut  the  vessels  are  cleanly  divided  and  nothing  is  left  to  prevent 
the  hemorrhage  at  once.  Hemorrhage  may  be  Arterial,  Venous 
or  Capillar}'',  depending  on  the  vessel  cut.  If  an  artery  is  cut,  we 
have  arterial  hemorrhage,  and  the  blood  is  of  a  bright,  crimson 
color  and  comes  in  spurts.  If  a  vein  is  cut,  w^e  have  venous  hemor- 
rhage, the  blood  is  of  a  dark  blue  color  and  welds  up  slowly  and 
steadily.     If  a  capillary  is  cut,  we  have  capillary  hemorrhage,  the 


PRINCIPLES    OF    SURGERY.  109 

blood  is  intermediate  in  color  and  comes  to  the  surface  like  sweat. 
Gaping  is  seen  in  all  wounds.  This  is  a  fortunate  provision,  as  it 
provides  tor  drainage.  It  is  due  to  the  elasticity  of  the  tissues. 
The  skin  is  the  most  elastic  tissue  in  the  body,  muscles  co?ne  next, 
and  in  a  wound  the  skin  retracts  showing  the  muscles  and  the 
muscles  retracting  more  than  the  fascia,  show  it  beneath. 

Complications.  — Local.  —Inflammation  is  not  a  natural  sequence^ 
but  a  complication  due  to  infection,  and  the  wound  fails  to  heal  by 
primary  intention.  It  becomes  red,  swollen,  oedematous  and  hot. 
The  treatraeni-  consists  in  asepsis  to  prevent  contamination  and  the 
general  treatment  for  inflammation  when  it  does  occur  as  laid  down 
previousl}'.  Suppuration  is  usually  a  sequence  of  inflammation. 
The  wound  becomes  infected  and  inflamed,  if  the  germ  is  virulent 
pus  forms  and  you  get  fluctuation  on  palpation.  The  treatment 
consists  of  preventing  the  complication  by  asepsis,  and  \^ hen  it 
occurs  the  general  treatment  for  suppuration  must  be  carried  out. 
Gangrene  occuring  in  a  wound  is  a  sequence  of  suppuration.  Thtj 
wound  becomes  inflam^ed,  suppurates  and  finally  there  is  death  of 
the  soft  tissues,  due  to  the  virulency  of  the  germ,  pressure  and  to 
the  direct  action  of  the  toxins  generated.  The  prevention  consists 
of  the  proper  treatment  of  the  wound,  and  when  gangrene  does 
occur  carry  out  the  treatment  as  laid  doT^  n  previously.  Erysipelas 
may  become  a  complication,  due  to  infection  by  the  Streptococcus 
Erysipelas.  The  treatment  is  the  same  as  for  erysipelas,  given 
elsewhere. 

Constitutional  complications. — Shock  may  be  a  complication,  due 
to  the  sudden  infliction  of  the  wound.  The  patient  falls  insensible, 
pulse  irregular,  respirations  shallow,  sub-normal  temperature,  pale 
face,  etc.  Treat  as  laid  down  previously.  Traumatic  delirium  is 
seen  after  wounds  to  the  genital  organs  or  after  severe  pain. 
There  is  no  fever,  hue  the  patient  talks  out  of  his  head,  tjssts  on 
the  bed,  mutters  to  himself  and  for  days  knows  nothing  of  his  con- 
dition, Thepatholog}'^  of  this  delirium  is  not  known,  it  usually  fol- 
lows laparotomies  for  the  removal  of  the  ovaries.  There  will  be 
little  shock,  but  when  the  patient  recovers  from  the  an^ieslhetic  this 
delirium  comes  on.  Delirium  tremens  is  a  complication  due  to  ex- 
cessive drinking.  It  occurs  in  hard,  continual  drinkers,  and  is  not 
seen   in  individuals   who   get  on   periodical  sprees.      A  man  who 


110  PRINCIPLES    OF    SURGERY. 

takes  tive  or  six  drinks  a  day,  but  who  was  never  drunk  in  his 
life,  il:  injured  or  operated  on,  is  extremely  liable  to  delirium 
tremens.  x\  typical  case  was  confined  in  the  Virginia  Hospital 
some  time  since.  He  was  a  respectable  looking  miner,  and  was 
suffering  from  a  compound  fracture.  He  was  hardy  and  robust, 
but  gradually  became  nervous  and  shaky.  He  said  he  never  ,vas 
drunk,  but  had  daily  taken  ten  drinks.  This  man  might  have 
gone  on  working  in  the  mines  all  his  life  and  not  been  bothered, 
but  receiving  this  fracture  caused  the  trouble.  He  commenced 
picking  at  the  bed  clothes,  tried  to  take  the  splint  off,  saw  women 
at  the  windows,  snakes  and  rats  in  the  room,  and  while  the  nurse 
was  absent  got  up  and  walked  around  the  room  regardless  of  the 
pain.  He  had  to  be  overpowered  and  tied  in  bed.  The  delirium 
comes  on  slowly,  they  answer  questions  intelligently,  but  remem- 
bers nothing  about  them  afterwards.  They  always  imagine  they 
see  women  at  the  windows  and  reptiles  in  the  room.  Fat  embolus 
may  be  a  complication.  An  individual  having  received  an  injury 
which  involves  the  fatty  tissue  or  fractures  a  bone,  macerating  the 
fat  in  the  medullary  cavity,  causing  it  to  disintegrate  and  become 
partly  liquified,  the  fat  may  enter  some  large  vein  or  lymphatic 
and  is  carried  to  the  heart.  From  there  it  is  pumped  into  the 
lunw,  where  it  lodges  in  some  small  bronchiole,  producing  fat  em- 
bolus. It  usually  occurs  from  tv\eaty-four  to  forty-eight  hours 
after  the  infliction  of  the  wound.  Up  to  this  time  the  patient  may 
have  been  doing  well,  when  suddenly  there  is  depression  and  ac- 
celerated breathing,  quickened  pulse  and  dyspnosa.  The  patient 
sits  up  in  bed,  gasps  once  or  twice  and  falls  back  dead;  or  the  em- 
bolus may  be  small  when  the  symptoms  are  not  so  alarming  and 
on  examining  the  urine,  fat  globules  va  ill  be  found  which  has  passed 
through  the  lungs  and  has  been  excreted  by  the  kidneys.  Septi- 
cemia, Pyemia  and  Tetanus  may  be  a  complication  and  has  been 
fully  discussed. 

Diagnosis. — The  diagnosis  is  simple,  but  is  more  difficult  to  tell 
the  nature  of  the  instrument  producing  the  wound. 

Pkogxcsis. — The  prognosis  depends  upon  the  nature,  character 
and  location  of  the  wound. 

Tkeatment. — 1.  Local. — Arrest  hemorrhage  and  always  use  the 
simplest  methods.     Never  apply  heroic  measures  unless  actually 


PRINCIPLES    OF    SURGERY.  Ill 

necessary,  as  tbey  retard  healing.  Elevate  the  part  which  acts 
by  diminishing  the  "w*  a  tcrgo''''  and  by  favoring  venous  return. 
Pressure  long  and  faithfully  applied,  either  as  a  tampon,  gauze  or 
sponge.  Heat  and  cold  are  useful,  but  cold  devitilizes  the  tissues 
and  retards  healing;  heat  is  ver}''  useful,  apply  a  tampon,  saturated 
in  water  at  110  degrees  F.,  to  the  bleeding  surface;  it  acts  not 
only  by  contracting  the  vessel,  but  also  coagulates  the  albumen  of 
the  blood.  If  all  these  means  fail,  use  torsion  or  ligate  the  vessel. 
In  using  torsion,  catch  the  vessel  -with  a  pair  of  haemostatic  forceps, 
and  twist  it  until  the  end  in  the  forceps  comes  off.  In  lighting  a 
vessel  use  aseptic  oat  gut  or  silk.  Catgut  is  the  best  if  you  are 
sure  it  is  aseptic,  as  it  will  be  absorbed. 

Secure  Asepsis.- — Make  the  wound  clean,  remove  any  gross  im- 
purities as  glass,  cloth,  garden  dirt,  etc.  If  there  are  any  slugs  of 
devitilized  tissue  remove  them.  Kow  endeavor  to  render  aseptic, 
go  about  this  gently  and  never  use  antiseptics  any  stronger  than 
actually  necessary,  a  1-1000  bi-chloride  solution  not  only  kills  the 
germs,  but  all  the  cells  it  comes  in  contact  with. 

Effect  accurate  coaptation. — It  is  your  duty  to  bring  the  surfaces 
in  apposition  accurately,  muscle  to  muscle,  fascia  to  fascia  and  skin 
to  skin.  If  it  is  a  trivial  wound  coaptation  may  be  effected  by 
placing  strips  of  adhesive  plaster  on  each  side  the  wound,  then 
stitch  from  one  piece  to  the  other  or  you  can  use  oolloidion  and 
cotton.  But  wounds  of  any  size  require  sutures.  Use  catgut  or 
silk  and  not  onlj^  suture  the  skin  together,  but  to  get  jjerfect  coap- 
tation, you  must  carry  your  sutures  deep  into  the  tivssues.  If  you 
do  not  carry  your  sutures  deep  enough  you  will  have  dead  spaces 
in  tbe  wound,  in  which  blood  clots  and  serum  stagnates,  causing 
pain  and  a  good  media  in  which  germs  can  grov\. 

Provide  for  drainage. — Owing  to  the  fact  that  you  can't  get 
perfect  haemostasis,  you  will  have  to  provide  for  drainage  or  else 
the  fluid  oozing  from  the  wound  wnll  collect  and  separate  the  lips 
of  the  wound  and  also  cause  severe  pain.  If  v^ou  do  not  fear 
hemorrhage,  use  capillary  drainage  by  inserting  into  the  bottom 
of  the  wound  and  letting  the  ends  project  out,  a  strip  of  gauze  or 
a  bundle  of  catgut  sutures.  If  suppuration  or  hemorrhage  is 
feared,  drainage  tubes  of  rubber  or  glass  are  best  to  use.  Remove 
the  drainage  tubes  as  soon  as  they  have  done  their  work,  usually 


112  PRINCIPLES    OF    SURGERY. 

after  tv\  enty-four  to  forty-eight  hours,  but  no  law  cau  be  laid  do^'^  n. 
Rubber  tubes  can  be  boiled  to  disinfect  them  without  injury. 

Apply  a  lyrotective  dressing. — The  object  of  this  dressing  is  two- 
fold, it  absorbs  the  secretions  and  prevents  infection  from  without. 
Gauze  or  cotton  can  be  used  and  should  be  impregnated  with  an- 
tiseptic solutions.  I  he  dressings  should  not  be  changed  any 
oftener  than  necessary,  but  as  often  as  the  case  demands.  It 
should  be  removed  if  there  is  fever,  pain  and  when  it  becomes 
saturated  with  the  secretions.  If  none  of  the  above  occur,  let  it 
remain  until  healing  occurs.  In  changing  the  dressing,  observe 
carefully  the  laws  of  asepsis. 

Mai7ita{n physiological  r^sz!.— Having  carried  out  the  above  in- 
dications, put  the  patient  in  bed  and  maintain  physiological  rest. 
If  the  eyb  is  injured,  exclude  light;  if  the  ear,  exclude  sound;  if 
the  intestines,  feed  per  rectum;  if  the  bladder,  give  drainage. 

li.  Genei^rd. — Eelieve  pain  by  giving  anodynes,  provided  they  do 
not  interfere  with  important  functions;  as  after  a  laparotomy  you 
would  not  give  opium,  as  it  constipates  vrhen  you  wish  free  action 
of  the  bowels.  Combat  complicaticns  as  septicemia,  pyemia,  ery- 
sipelas, etc.,  and  when  they  occur,  treat  them  as  laid  dovyn  pre- 
viously. Encourage  the  patient,  give  whiskey  as  a  stimulant  aad 
last,  but  not  least,  give  plenty  of  good  nourishing  food. 


LECTURE  XXVI. 


SPECIAL    WOUNDS. 

Incised  Wounds. — An  incised  wound  is  a  wound  made  by  an  in- 
strument possessing  a  smooth,  sharp,  cutting  edge,  and  is  char- 
acterized by  the  fact  that  only  the  cells  directly  in  the  path  of  the 
instrument  are  killed.  The  wound  does  not  slough  and  is  easily 
repaired.  Such  wounds,  if  coaptation  is  effected,  will  heal  in  ten 
or  twelve  days  by  primary  intention.  These  wounds  build  up  a 
surgeons  reputation. 


PRINCIPLES    OF    SURGERY.  113 

Causes.— These  wounds  are  either  inflicted  on  the  operating 
table  by  a  surgeon  with  a  scalpel  or  scissors,  or  accidentRlly  by  a 
sword,  butcher's  knife,  hatchet  or  glass.  They  are  constantly 
occuring  and.  demand  the  surgeon's  attention. 

Sy]\[ptoms. — The  symptoms  are  pain,  which  is  immediately  felt, 
is  sharp,  severe  and  cutting  in  character,  and  unless  the  wound  is 
infected  subsides  in  a  few  hours;  hemorrhage,  which  is  profuse  on 
account  of  the  vessels  being  cleanly  divided,  the  amount  depend- 
ing on  the  vessel  cut;  gaping  is  considerable,  and  is  only  limited 
by  the  contractility  and  elasticity  of  the  tissues  passed  through. 

Treatment. — As  these  wounds  heal  readily,  the  treatment  is  that 
for  wounds  in  general.  Arrest  hemorrhage  by  pressure,  elevation 
and  hot  applications,  if  these  fail  use  torsion  or  ligate  the  vessel. 
ISTever  use  styptics,  such  as  Persulphate  iron,  Monsel's  solution, 
etc.,  it  is  true  they  arrest  hemorrhage,  but  do  so  by  destruction  of 
the  superficial  cells,  coagulating  the  albumen  and  thus  retard  heal- 
ing. Secure  asepsis  by  washing  the  wound  and  surrounding  skin 
with  green  soap,  alcohol  and  a  bi-chloride  solution.  Approximate 
the  surfaces,  either  by  sutures,  laying  a  piece  of  adhesive  plaster 
on  each  side  and  stitch  from  one  piece  to  the  other,  or  by  gauze 
and  collodion.  I^ever  put  adhesive  plaster  in  direct  contact  with 
a  wound,  and  it  is  no^  even  safe  to  put  it  across  a  wound  separated 
by  gauze  or  cotton.  Drainage  is  not  usually  necessary  in  these 
wounds.  Apply  a  dressing  of  gauze  or  cotton  and  bind  it  firmly 
with  a  roller  bandage.  Unless  one  of  the  three  indications,  fever, 
pain  and  a  saturated  dressing  be  evinced,  do  not  remove  the  dress- 
ings for  four  or  five  days,  and  in  that  time  the  stitches  can  be  re- 
moved. 

Lacerated  and  Contused  Wounds. — A  lacerated  wound  is  made 
by  some  tearing  force.  A.  contused  wound  is  made  by  some 
crushing  force.  It  is  at  once  evident  then,  from  the  causes  of 
these  two  varieties  of  wounds,  that  they  are  always  combined;  an 
instrument  that  makes  a  tearing  wound  crushes  at  the  same  time, 
as  a  wound  made  by  a  cog  wheel;  and  a  force  making  a  crushing 
wound  also  tears,  as  in  a  blow  from  a  brick.  The  two  then  will 
be  considered  together.  The  characteristic  of  these  wounds  is  the 
excessive  destruction  of  tissue;  cells  distant  from  the  wound  are 
devitilized,  causing  necrosis  and  making  it  impossible  for  the  wound 


114  PRINCIPLES    OF    SURGERY. 

to  heal  by  piimar}'-  intention.  The  best  that  can  be  hoped  for  is 
that  the  devitilized  tissue  will  separate  by  dry  necrosis. 

Cause.. — These  causes  are  numerous  and  have  already  been 
enumerated.  These  wounds  are  much  more  common  now  than 
they  were  twenty  years  ago,  owing  to  the  invention  of  large  quan- 
tities of  machinery. 

Symptoms. — Hemorriiage  is  not  great  at  the  time  of  infliction, 
although  large  vessels  may  have  been  severed;  this  is  due  to  the 
mechanica]  closure  of  the  vessels  by  the  grinding  and  pressure  of 
the  force  causing  the  wound,  and  the  ends  of  the  vessels  are  left 
ragged,  and  the  blood  flowing  over  it  causes  it  to  coagulate  and 
arrest  the  hmorrhage.  But  hemorrhage  may  come  on  later  and 
it  is  your  duty  to  find  any  large  vessels  that  have  been  severed  and 
ligate  them.  Shock  is  always  present  in  this  variety  of  wounds, 
but  is  seldom  seen  in  incised  wounds.  This  helps  to  explain  why 
we  have  hemorrhage  immediately  in  incised  wounds  and  none  in 
lacerated  wounds,  as  in  lacerated  wounds  the  heart  is  depressed 
from  shock,  and  is  not  in  incised  wiounds.  Pain  is  sometiires  en- 
tirely absent,  the  severe  injury  obtunding  the  sensibility  at  the 
time,  hut  there  is  excruciating  pain  soon  after  the  injury. 

Treatment. — All  lacerated  and  contused  wounds  are  infected, 
and  the  most  difficult  and  important  task  is  their  disinfection.  A 
man  dragged  underneath  a  car  wheel  has  every  description  of  filth 
in  his  wound,  clothes,  manure,  cinders,  gravel,  etc. ;  a  man  injured 
by  a  cog  wheel  in  a  factory  has  dirty  hands,  besides  the  wound  is 
contaminated  by  the  filthy  lubricating  oil  on  the  wheel.  The  first 
indication  is  to  clean  the  hand,  give  an  anaesthetic;  grease  the  hand 
with  sweeli  oil,  this  oil  is  also  infected,  but  it  removes  the  grease 
and  dirt;  now  wash  it  with  green  soap  and  a  nail  brush,  com- 
mencing six  or  eight  inches  from  the  wound  and  finally  attacking 
it,  then  wash  with  alcohol  to  remove  the  soap  and  also  for  its  an- 
tiseptic properties,  and  lastly  wash  in  a  bi-chloride  or  carbolic  acid 
solution.  Decide  how  you  will  treat  the  wound;  iC  it  is  necessary 
amputate;  if  not,  remove  all  the  dead  lacerated  tissue  with  a  pair 
of  curved  scissors,  take  out  all  splinters  of  bone,  remove  your  tour- 
niquet and  tie  all  bleeding  vessels.  Xever  approximate  the 
wounded  surfaces,  for  it  is  almost  impossible  for  you  to  remove 
all  the  dead   tissue  and  it  won't  do  to  close  the  wound  v^ith  dead 


PRINCIPLES    OF    SURGERY.  115 

tissue  in  it.  So  leave  it  open,  dust  with  lodofoim,  pack  with 
gauze  and  dress  with  plenty  of  absorbing  cotton.  ISTever  let  the 
dressing  remain  long  enough  to  become  saturated.  "Watch  the 
patient,  don't  leave  him  unless  you  leave  a  competent  nurse  who 
can  apply  a  tourniquet  if  necessary,  as  there  is  danger  of  slough- 
ing or  the  heart's  action  becoming  stronger  after  reaction,  causmg 
dangerous  hemorrhage.  If  the  wound  be  infected  there  may  be 
necrosis  or  even  gangrene.  After  healthy  granulations  appear, 
the  wounded  surfaces  may  be  approximated  by  what  is  called 
secondary  suturing. 

Punctured  "Wounds. — These  wounds  are  caused  by  pointed  in- 
strumeats.  'i'hey  are  characterized  by  occupying  only  a  small  sur- 
face, but  penetrating  deep  into  the  tissues,  the  outward  appear- 
ance being  no  evidence  of  the  severity  of  the  injury. 

Cause. — Any  pointed  instrument,  as  a  needle,  pin,  stiletto  or 
dagger.  Wounds  made  by  these  instruments  resemble  incised 
wounds,  as  they  are  all  clean,  sharp  edged  instruments.  A  splinter 
of  wood,  nail  or  fence  paling,  causes  a  punctured  wound,  but  they 
make  wounds  resembling  lacterated  or  contused  wounds,  and  there- 
fore the  nature  of  the  wound  depends  on  the  character  of  the  in- 
flicting instruirent. 

Symptoms.  — The  symptoms  depend  on  the  location  of  the  wound. 
Hemorrhage  is  not  usually  great,  unless  some  great  blood  vessels 
lay  directly  in  the  track  of  the  penetrating  instrument  and  is 
punctured.  The  amount  of  pain  depends  on  the  nature  of  the  in- 
strument; if  it  is  produced  by  a  sword,  the  pain  is  considerable, 
but  if  produced  by  a  dull  instrument  like  a  paling,  the  pain  is  not 
so  severe.  The  amount  of  shock  depends  on  the  nature  of  the  in- 
stilment, a  sharp  edge  causing  less  shock  than  a  blunt  instrument. 
When  an  instrument  like  a  dagger  is  stuck  into  a  cavity,  as  the 
abdomen,  and  the  point  does  not  appear  on  the  opposite  side,  it  is 
called  a  Penetrating  wound;  if  the  point  does  show  on  the  back 
or  side,  it  is  called  a  Perforating  wound. 

Treatment. — The  treatment  depends  on  the  anatomical  location 
and  the  nature  of  the  instrument  inflicting  the  wound.  If  the  in- 
strument punctures  some  important  cavitv  or  blood  vessel  interfer- 
ence is  justifiable,  but  if  the  wound  is  made  by  a  clean,  sharp  in- 
strument like  a  dagger,  and  does  not  involve  any  important  organ, 


116  PRINCIPLES    OF    SURGERY. 

cavitv  or  blood  vessel,  all  that  is  necessary  is  to  wash  the  surface 
of  the  wound  with  green  soap,  alcohol  and  a  bi-chloride  solution 
and  apply  an.  occlusive  dressing.  If  the  wound  was  inflicted  by  a 
paling  or  rusty  nail,  it  is  3^our  duty  to  lay  the  wound  open  with  a 
free  incision  down  to  the  very  bottom  of  the  tract,  thoroughly  dis- 
infect it,  pack  i\'ith  gauze  and  allow  it  to  heal  by  granulation.  In 
a  wound  made  by  a  knife,  dagger  or  needle,  the  infection  is  wiped 
off  ot  it  by  the  skin  and  clothes  and  superficial  disinfection  is  all 
that  is  needed;  but  in  the  case  of  a  nail  or  paling,  the  wound  is 
infected  to  its  very  bottom,  and  you  can't  disinfect  it  without 
splitting  the  part  open. 

Gunshot  "Wounds. — On  this  subject  volumns  have  been  written, 
but  now  in  these  civil  times  their  occurrence  is  so  rare  we  need 
only  give  its  consideration  a  passing  glance.  Gunshot  wounds  are 
caused  by  missiles  that  have  been  projected  b}  force  derived  from 
explosives.  They  are  characterized  by  partaking  of  the  nature  of 
both  punctured  and  lacerated  wounds;  punctured  because  the 
missile  penetrates  deeply  and  only  shows  a  slight  wound  on  the 
surface;  lacerated  because  the  tissues  are  crushed  and  torn  into. 

Causes. — The  causes  are  numerous.  Any  missile  from  a  small 
bird  shot  to  a  mammoth  shell.  The  most  common  causes  are 
missiles  fired  from  shot  guns,  pistols  and  rifles.  A  shot  gun  at 
short  range  makes  a  round  hole  like  a  pistol  ball,  and  it  is  hard  to 
tell  one  from  the  other.  A  pistol  bullet  varies  from  a  23  to  a  48 
calibre,  which  designates  the  diameter  of  the  bail  in  decimals  of  an 
inch.  They  are  usually  round,  and  do  not  possess  very  great 
penetrating  power.  The  rifle  ball  has  changed  considerably  in  re- 
cent years.  They  formerly  weighed  as  much  as  an  ounce,  but  are 
now  only  30  calibre,  coated  with  nickle,  round  or  cone  ?haped  and 
more  penetrating  than  the  old  ball.  A  round  bullet  produces  a 
contused  bruised  wound,  whereas  a  cone  shaped  bullet  acts  as  a 
wedge  and  produces  a  lacerated  wound.  The  velocity  of  the  old 
rifles  was  only  two  or  three  hundred  yards;  the  new  rifle's  velocity 
is  from  one  to  two  miles.  In  a  smooth  bore  rifle  the  bullet  rotates 
at  right  angles  to  its  axis;  a  rifled  bore  causes  it  to  rotate  in  a  line 
with  its  axis.  A  round  bullet  produces  ecchymosis  at  the  point 
of  entrance,  mashes  and  lacerates  the  tissue,  and  has  little  pene- 
trating power;  the  cone  shaped  ballet  possesses  great  penetrating 
power  and  if  it  strikes  a  bone  it  shatters  it. 


PRINCIPLES    OF    SURGERY.  117 

Sympto^[s. — Pain  is  variable.  Mea  in  the  excitement  of  battle 
have  been  shot  without  being  aware  of  it.  During  the  late  war  a 
gallant  officer  was  shot  through  the  tibial  artery  and  never  knew 
he  was  shot,  until  an  orderly  told  bim  his  boot  was  running  over 
w^ith  blood.  Other  individuals  will  suffer  horribly  froo:  slight 
wounds.  The  pain  also  varies  with  the  kind  of  bullet  struck  with, 
a  round  ball  causing  more  pain  than  a  cone  shaped  ball.  Old 
soldiers  tell  us  they  felt  as  if  they  had  been  struck  by  an  axe  when 
shot.  The  amount  of  hemorrhage  depends  on  the  anatomical  loca- 
tion ;  if  a  large  artery  is  severed,  it  will  be  severe  and  is  greater  in 
a  wound  produced  by  a  cone  shaped  ball  than  when  produced  by 
a  round  ball.  Shock  is  generally  profound,  especially  in  soldiers 
that  have  been  fighting  all  day  without  food  or  drink.  Thirst  is 
an  invariable  accompaniment,  but  why,  we  do  not  know. 

Injukies  to  Special  Tissues.— When  a  person  is  shot,  and  the 
ball  perforates  the  entire  body,  the  point  of  exit  will  be  larger 
than  the  point  of  entrance;  this  is  due  to  the  fact  that  the  velocity 
of  the  ball  is  lessened  and  the  skin  at  the  point  of  exit  has  no  sup- 
port. It  is  the  same  principle  as  driving  a  nail  through  a  plank, 
the  point  of  exit  will  be  larger  and  shattered  from  non-support. 
The  skin  is  usually  livid  and  soiled  with  grease  from  the  bullet. 
The  fascia  is  peculiarly  affected;  made  up  as  it  is  of  interlacing 
fibres  of  conaective  tissue,  the  ball  does  not  tear  through  it,  but 
pushes  the  fibres  aside  and  the  hole  closes  again.  This  is  unfor- 
tunate, for  it  prevents  drainage  and  is  also  a  bother  in  probing  for 
the  ballet.  It  also  may  cause  the  ball  to  he  deflected  from  its 
course,  either  lessening  the  injury  or  causing  greater  damage. 
Muscles  are  bruised  and  pulpified.  Tendons  usually  escape  the 
ball  by  slipping  to  one  side.  Blood  vessels,  if  situated  so  as  to  be 
able  to  slip  to  one  side,  may  escape,  but  the  modern  bullet  usually 
penetrates  them.  Bonos  were  only  perforated  by  balls  from  the 
old  rides,  but  the  modern  rifles  and  balls  splinter  them  into  a  hun- 
dred fragoaents;  so  in  the  next  war  compound  fractures  will  be 
more  common.  ISTerves  are  usually  severed  on  account  of  being 
situated  deeply,  and  often  supported  by  bon'^.  Great  cavities  as 
the  skull  or  abdomen  may  be  penetrated.  The  abdomen  may  be 
punctured,  producing  serious  damage,  although  the  bowels  may  be 
pushed  aside  and  escape  injury. 


118  PRINCIPLES    OF    SURGERY. 

Diagnosis. — The  diagnosis  is  based  on  the  history;  the  fact  of 
having  been  shot  and  on  the  appearance  of  the  Tvound, 

Peognosis. — The  prognosis  depends  on  the  nature  of  the  injury, 
temperature  and  anatomical  location.  If  the  temperature  fails 
below  normal,  say  96  degrees  F.,  the  prognosis  is  very  grave. 

Treatment. — Stop  the  hemorrhage,  relieve  pain  and  combat 
shock;  do  all  this  on  the  field  of  battle  or  at  the  place  of  accident. 
There  are  many  disadvantages  in  treating  these  wounds  even  in 
civil  life.  You  are  alwa^^s  called  to  the  country  or  hunting  field 
where  you  are  nut  prepared  for  emergencies.  But  you  should  al- 
ways be  equal  to  the  occasion;  put  on  a  tourniquet,  give  morphia 
for  the  pain  and  whiskey  for  the  shock  until  you  can  remove  him 
to  better  surroundings.  The  local  treatment  is  all  that  is  neces- 
sary, disinfect  the  a'^  ound  and  apply  a  dressing.  Don't  go  probing 
after  the  ball,  it  will  become  encapsulated  and  do  no  harm,  and  if 
it  does  you  can  take  it  out  when  the  patient  is  better  prepared  to 
stand  the  operation.  The  rule  given  to  assistant  surgeons  United 
States  Army  is  \vhen  a  man  is  shot  in  battle,  do  nothing  but  ar- 
rest the  hemorrhage,  relieve  the  pain  and  combat  shock,  then  send 
the  man  to  the  rear,  and  if  he  has  no  vital  organ  involved  he  is 
left  unmolested.  If  called  t^^  a  person  shot  in  the  brain  or  abdo- 
men you  must  operate  at  once,  and  under  the  strictest  asepsis. 
The  finger  is  the  best  probe,  and  always  use  it,  unless  the  tract  is 
too  deep;  then  use  a  Xelatou's  probe,  ^hich  is  the  best  artificial 
probe  we  have;  it  expandsinto  a  brlb  at  one  end  v;hich  is  covered 
with  porcelain  and  when  it  comes  in  contact  ^vith  the  lead,  marks 
are  left  on  it,  Xo  two  cases  are  treated  alike,  you  must  simply 
meet  every  indication.  Disinfect  the  wound,  making  it  larger  if 
necessary  with  a  free  incision,  remove  the  ball  if  indicated,  arrest 
hemorrhage  and  apply  an  occlusive  dressing. 


PRINCIPLES    OF    SURGERY.  119 


LECTURE  XXVII, 


SPECIAL  WOUj^DS.— Continued. 

Arrow  Wounds. — Arrow  wounds  are  wounds  inflicted  bv 
arrows.  They  are  characterized  by  the  fact  that  they  present 
features  of  both  punctured  and  contused  wounds. 

Cause. — The  cause  is  an  arrow  head  of  stone  fastened  to  a  shaft 
by  leather  fired  from  a  bow, 

Stmptons. — The  symptoms  are  those  of  a  punctured  and  con- 
tused wound  in  general.  The  shaft  is  usually  seen  projecting  from 
the  wound. 

Treatment. — An  arrow  head,  unlike  a  bullet,  will  not  become 
uncapsulated,  and  if  allowed  to  remain  in  the  tissues  will  cause 
suppuration,  and  therefore  no  matter  where  it  is  situated  it  must 
be  removed.  The  common  mistake  is  to  try  and  withdraw  the 
head  by  making  traction  on  the  shaft.  IsTever  do  this,  for  you 
will  pull  the  head  frorr  the  shaft  and  thus  lose  the  shaft  as  a  guide 
in  operating.  If  the  arrow  almost  perforates  a  limb,  it  is  best  to 
push  on  the  shaft  until  the  head  shows  on  the  opposite,  incise  the 
skin  and  remove  it.  But  if  th^  arrow  is  stopped  by  a  bone,  you 
must  dissect  down  to  the  head,  following  the  shaft  as  a  guide,  re- 
move it  with  forceps,  disinfect  thf'  wound  with  a  bi-chloride  solu- 
tion, pack  with  gauze  and  dress  the  wound.  The  rule  given  in 
case  of  a  bullet  wound  on  a  battle  field  holds  good  here;  do  noth- 
ing  on  the  field  but  relieve  the  pain,  clip  the  shaft  off  two  oi  three 
inches  from  the  wound,  put  on  an  occlusive  dressing  and  remove 
the  patient  to  the  hospital  for  further  treatment. 

Brush  Burns. — This  is  a  superficial  abrasion  produced  by  the 
contact  of  some  rapid  moving  substance  against  the  soft  tissues  of 
the  body.  They  may  be  produced  by  the  soft  tissues  coming  in 
contact  with  a  rapidly  moviag  belt  on  a  piece  of  machinery,  a  rope 
slipping  rapidly  through  the  hands  or  by  an  involuntary  slide  down 
an  incline  (as  a  cellar  door).  They  are  characterized  by  the  fact 
that  the  superficial  tissues,  which  come  in  contact  with  the  mov- 
ing body,  is  killed,  leading  a  deep  eschar,  with  no  hemorrhage,  but 


120  PRINCIPLES    OF   SURGERY. 

intense  pain.  Later  the  eschar  sloughs,  leaving  a  raw  surface 
which  heals  slowly. 

Tkeatmekt.— The  treatment  consists  of  thorough  disinfection, 
the  application  of  an  antiseptic  compress  for  two  or  three  days, 
when  the  scab  will  be  separated,  then  treat  as  any  superficial  ex- 
posed wound. 

Dissecting  Wounds,  —Dissecting  wonuds  are  wounds  caused  by 
the  introductioaof  septic  material  into  the  system  from  dead  putre- 
fying organic  bodies.  They  occur  chiefly  in  surgeons  and 
students  who  conduct  post-mortem  examinations  and  in  butchers 
iand  cooks,  who  handle  putrefying  organic  matter. 

Cause. — The  exact  nature  of  the  poison  causing  the  trouble  is 
not  known,  it  arises  from  putrefaction  of  organic  matter.  For 
the  development  of  grave  symptoms,  the  poison  must  be  exceed- 
ingly virulent  or  the  person  infected  must  be  in  a  state  of  lowered 
vitality.  In  a  strong,  robust  individual,  the  symptoms  are  not 
marked;  neither  are  they  marked  if  the  poison  is  weak  and  the  in- 
dividual debilitated,  but  if  the  individual  is  weak  and  the  poison 
virulent,  the  symptoms  are  severe,  and  death  often  results.  There 
must  be  an  '■'■infection  atrium,''''  for  the  perfect  unbroken  skin  acts 
as  a  barrier  against  infection,  but  if  a  student  is  pricked  by  the 
pcint  of  a  dissecting  knife,  or  he  has  hang  nails  or  a  little  sore  on 
his  finger,  he  is  liable  to  become  infected. 

Symptoms. — The  symptoms  vary  extremely.  They  may  be  from 
a  slight  irritation  or  suppuration  to  chat  of  rapid  progressive  gan- 
grene. Soiretimet  the  wound  becomes  red,  swollen  and  inflamed 
and  then  subsides;  again,  other  cases  will  make  rapid  progress  for 
the  w3rse,  red  lines  will  rrark  the  h'^mphatics  near  the  wound;  the 
part  becomes  oedematous  and  stvollen,  extreme  depression  and 
death  follows. 

Treatment. — Don't  dissect  or  come  in  contact  with  putrefying 
organic  matter  with  abrasions  on  the  skin.  But  if  while  making 
a  post-mortem  examination,  or  vvhile  dissecting  or  handling  putre- 
fying organic  matter  an  individual  is  wounded,  you  must  heroically 
disinfect  the  wound.  Withdraw  the  poison  by  suction,  examine 
the  wound,  and  if  it  is  small  and  punctured,  enlarge  it  and  irrigate 
wath  a  1-500  bi-chloride  solution  or  touch  it  with  chloride  zinc, 
dust   with   iodoform  and  dress.      If  no  symptoms  develop  in  three 


PRINCIPLES    OF    SURGERY.  121 

days  the  patient  is  safe  and  must  simply  wait  for  the  wound  to 
ileal,  but  if  the  above  symptoms  develop,  and  the  wound  goes  from 
bad  to  worse,  don't  v^ait  for  the  formation  ot  pus,  but  make 
numerous  free  incisions  through  the  inflaired  tissues  parallel  with 
the  long  axis  of  the  limb,  and  thus  let  the  secretions  escape;  disin- 
fect the  part,  apply  occlusive  dressings  and  treat  on  general  surgi- 
cal principles.  If  abscesses  form  on  the  body,  incise  and  irrigate 
them.  Give  constitutional  remedies,  as  the  patient  mav  have  the 
complication  of  septicemia.  Give  quinine  in  tonic  doses,  iron  to 
tone  up  the  system  and  increase  the  red  corpuscles,  strychnia  as  a 
cardiac  stimulant,  whiskey  and  plenty  of  concentrated  nourishing 
food. 

Stings  of  Insects,  —These  are  punctured  wounds,  inflicted  by 
the  bite  of  various  small  animals.  Although  trivial  in  most  in- 
stances, as  the  bite  of  a  flea,  bed  bug  or  louse,  they  are  exceed- 
ingl}^  painful  when  inflicted  by  a  yellow  jacket,  wasp,  bee  and 
hornet.  The  bite  of  the  spider,  centipede,  tarantulge  and  scorpions 
mav  producel  alarming  symptoms.  These  wounds  are  character- 
ized not  only  as  a  punctured  wound,  but  by  the  injection  of  poison 
into  the  wound  at  the  same  time.  The  poison  comes  from  some 
gland,  may  be  mixed  with  the  saliva,  and  it  is  important  to  know 
in  the  treatment  that  the  poison  from  all  insects  is  acid  in  reaction. 

Symptoms. — The  symptoms  depend  on  the  animal  inflicting  the 
wound.  The  local  sj^mptoms  are  a  mild  inflammation,  irritable 
pain,  heat  and  swelling.  If  the  wound  be  examined,  it  will  be 
found  to  be  a  small  puncture  and  the  sting  wdll  be  protruding  from 
it.  The  constiluiional  symptoms  are  cardiac  depression,  interfer- 
ence with  respiration,  collapse  and  in  some  cases  death  results. 

Treatment. — Examine  the  wound  and  remove  the  sting,  disin- 
fect c:.nd  apply  an  occlusive  dressing  to  prevent  infection.  Eelieve 
the  pain  by  the  use  of  some  alkali,  as  ammonia  or  bicarbonate  soda. 
Prevent  complications.  If  the  wound  is  made  where  the  above 
remedies  can't  be  had,  iiake  a  poultice  out  of  the  soil  and  apply  it 
to  the  w^ound  to  relieve  the  pain.  The  constitutional  treatment 
consists  of  meeting  the  symptoms  as  they  develop,  strychnia  for 
cardiac  depression  and  quinine  as  a  tonic. 

Bites  of  Serpents. — These  are  wounds  inflicted  by  the  fangs  of 
poisonous   snakes.     They  are   rarely   seen  in  this  section,  but  are 


122  PRINCIPLES    OF    SURGERY. 

common  in  the  mountainous  regions  of  Yirginia  and  North  Caro- 
lina, The  importance  of  this  subject  will  be  recognized  when  you 
learn  that  in  India  20,U00  people  die  annually  from  snake  bites. 
In  India  twenty  poisonous  varieties  are  known,  whereas  in  this 
country  we  only  have  four,  rattlesnake,  adder,  moccasin  and  in 
Texas  the  "Gila  monster.*'  Of  course,  there  are  many  different 
varieties  of  each,  of  the  above,  but  there  are  only  four  great  fami- 
lies. The  poision  from  each  are  almost  identical  in  nature,  the 
treatment  for  each  the  same,  and  therefore  they  ^ill  be  considered 
together. 

Description. — A  poisonous  snake  is  always  short,  with  a  blunt 
tail  and  a  coffin  shaped  head.  The  upper  jaw  is  movable,  being 
on  a  joint,  so  that  in  addition  to  opening  its  mouth  with  its  lower 
jaw,  it  can  raise  the  upper  jaw  and  can  therefore  swollow  an  obj-^ct 
as  large  as  its  head.  This  arrangement  of  the  jaw  is  peculiar  to 
the  snake  and  crocodile.  Snakes  have  teeth,  tut  they  do  not  use 
them  in  inflicting  wounds.  For  inflicting  wounds  they  have  fangs, 
which  occupies  the  position  of  the  canine  teeth  of  the  upper  javv; 
they  are  about  three-quarters  of  an  inch  long,  sharp  pointed  and 
curved  like  a  scythe.  They  are  not  hollow,  but  mucous  memberane 
runs  down  behiQd  them  and  thus  converts  them  into  a  kind  of  hy- 
podermic syringe.  They  are  movable,  and  when  not  in  actiou  lay 
back  on  the  roof  of  the  mouth.  They  are  two  in  number,  one  on 
each  side.  The  poison  is  contained  in  a  sack  situated  behind  the 
eye,  which  communicates  by  a  duct  (which  has  a  sphincter  muscle, 
so  as  not  to  allow  the  poison  to  escape  except  when  voluntarily 
relaxed)  with  the  canal  behind  the  fang.  The  poison  varies  in 
color  from  a  pale  green  to  a  dark  orange,  it  is  thick  and  transpa- 
rent, resembling  light  molasses.  It  is  of  an  acid  reaction  and  from 
ten  to  fifteen  minims  in  bulk.  The  venom  is  the  most  powerful 
organic  poison  known;  chemists  have  tried  to  analyze  it  without 
success.  One  chemist  says  that  rattlesnake  poison  contains  two 
proteids,  which  causes  its  dangerous  effects.  The  poison  acts  on 
tissues  peculiarly.  It  causes  necrosis  of  the  cells  that  it  comes  in 
contact  with  and  produces  uncoagubility  of  the  blood.  A  case  in 
which  death  resulted  on  post-mortem  the  blood  was  found  perfectly 
fluid,  and  would  not  coagulate  after  exposure  to  the  air  in  cans. 
The  red   corpuscles   lose   their   shape,    disintegrates  and   run   to- 


PRINCIPLES    OF    SURGERY.  123 

gether.  The  capillaries  lose  tbeir  elasticity  and  not  being  able  to 
withstand  the  blood  pressure,  the  blood  is  forced  out  into  the 
tissues.  The  poison  acts  too  quickly  for  inliammation  to  occur. 
When  a  snake  bites  be  does  so  in  this  way:  Seeing  an.  approaching 
enemy,  he  curls  up,  only  leaving  his  head  and  about  two  inches  of 
his  body  out,  his  tail  vibrates,  head  moves  from  side  to  side,  eyes 
flashes,  the  body  becomes  stiff  and  the  muscles  of  the  back  acting, 
sends  the  head  forw^ard,  burying  the  fangs  deep  into  the  enemy; 
he  then  shakes  his  head  from  side  to  side  to  extricate  the  fangs.  A 
snake  can'r  jump  over  two-thirds  his  length,  and  can't  bite  while 
running;  he  must  be  coiled  up. 

Symptoms. — Local.  —  Examine  the  wound,  and  it  will  shov^  two 
parallel  punctures  about  one  inch  apart.  The  surrounding  tissues 
are  black,  gangrenous,  swollen,  oedematous,  and  soon  disintegrate. 
The  pain  is  severe  and  gradually  grows  worse.  Constitutional. — 
There  is  giddiness  at  the  time  of  infliction,  becoming  fainty,  nause- 
ated, the  skin  is  cold  and  clammy,  heart  weak  and  intermittent, 
respirations  depressed,  delirium,  collapse,  coma  and  death  from 
paralysis  of  respiration. 

Diagnosis. — The  diagnosis  is  based  on  tae  history,  local  symp- 
toms, a  double  punctured  wound,  change  in  the  tissues  and  on  the 
snake  itself. 

Prognosis. — The  prognosis  depends  on  the  variety  of  snake  in- 
flicting the  wound  and  the  amount  of  poison  injected.  The  bite  of 
a  Cobra  is  always  fatal,  whereas  a  rattlesnake  bite  need  not  be  fatal 
if  heroic  treatment  is  adopted.  A  snake  has  but  ten  drops  of  poi- 
son, and  if  the  wound  was  inflicted  through  the  clothing,  part  of 
it  will  be  lost  or  if  the  snake  bites  the  dog  which  is  accompanying 
the  hunter,  and  then  bites  the  hunter,  the  prognosis  for  the  hunter 
is  good,  bnt  bad  for  the  dog,  as  the  dog  received  nearly  all  the 
poison  from  being  bitten  first. 

Treatment. — The  treatment  must  be  prom  pt  and  heroic.  At  ply 
a  tourniquet  at  once  between  the  wound  and  the  heart.  On  ac- 
count of  the  length  of  snake-;  in  this  country  and  their  inability  to 
reach  over  two-thirds  their  length,  the  v^ound  is  generally  on  the 
extremities.  If  the  wound  is  on  the  foot,  apply  the  tourniquet 
about  the  knee;  if  on  the  hand,  apply  it  below  the  elbow.  As 
these  wounds  usually  occur  in  the  field  or  woods,  you  will  not  have 


124  PRINCIPLES    OF    SURGERY. 

the  necessary  appliances,  you  will  have  to  provide  a  tourniquet  on 
the  spur  of  the  moment;  take  a  handkerchief  or  grape  vine,  put  it 
around  the  limb  and  twist  it  tight  with  a  stick.  As  soon  as  this  is 
done  make  an  effort  to  withdraw  the  poison,  split  open  the  part 
vfith  a  scalpel  and  let  it  bleed,  then  with  a  cupping  glass  or  by 
sucking  (be  sure  you  have  no  crack  or  fissure  on  your  lips)  remove 
the  poison.  If  you  are  near  a  house,  use  a  tumbler  as  a  cupping 
glass.  iSiow  thoroughly  disinfect  the  ^vound,  using  the  hoi  iron, 
nitrate  of  silver  or  a  strong  bi- chloride  solution.  The  constiutional 
treatment  is  important,  and  for  this  purpose  whiskey  is  ^'^■par  ex- 
cellence^'''' but  remember  it  is  not  a  chemical  antidote,  but  only  a 
heart  stimulant,  and  oaly  give  it  to  its  stimulating  extent.  As 
many  people  have  been  killed  by  whiskey"  given  in  excessive  quan- 
tities as  by  the  snake  poison.  After  the  pulse  and  respirations 
improve  you  will  wonder  what  to  do  with  the  tourniquet,  you 
can't  leave  it  on,  as  it  will  produce  gangrene,  and  you  can't  take 
it  off,  for  you  know  there  is  still  enough  poison  in  the  limb  to  im- 
mediately kill  the  patient  if  it  is  allowed  to  get  in  the  circulation. 
You  can't  remove  the  poison,  so  the  only  thing  to  do  is  to  give  it 
to  him  in  broken  doses.  Take  the  tourniquet  off  for  a  half  a  min- 
ute, reapply  it,  stimulate  the  patient  with  whiskey  and  digitalis 
until  the  pulse  again  regains  itself,  repeat  the  operation  and  keep 
on  doing  so  until  the  patient  is  out  of  danger  and  all  the  poison  has 
been  introduced  into  the  system. 

Note. — At  the  springs  three  years  ago  there  was  a  young  natu- 
ralist, lie  w^as  making  at  that  time  a  special  study  uf  reptiles. 
He  bought  tbe  snakes  from  the  mountaineers  and  with  a  scalpel  he 
dissected  them.  The  scalpel  usually  lay  upon  his  desk,  posing  as 
a  piece  of  ornament  to  his  room.  While  at  the  springs  he  fell  in 
love  with  a  beautiful  girl,  whose  name  was '"Carrie."  One  day, 
V  hile  revelling  in  the  enchanting  dreams  of  this  fair  one,  he  care- 
lessly picked  up  his  scalpel  and  began  to  trace  her  name  upon  his 
arm.  As  he  dreamed  of  his  love,  ardently  and  passionately,  he 
traced  and  retraced  the  letters  cf  her  name  until  they  stood  out 
bathed  in  his  own  blood.  Suddenly  pain  and  swelling  peculiar  to 
snake  bite  developed,  and  in  great  haste  I  was  called  in  to  see 
him.  When  I  arrived  he  had  all  the  symptoms  of  a  snake  bite,  but 
said   he   had   not  been  bitten,  but  had  been  scratching  on  his  arm 


PRINCIPLES    OF    SURGERY.  125 

Tvith  the  scalpel  which  he  used  for  his  dissections.  The  first  thing 
obtainable  was  a  solution  of  Xitrate  of  Silver,  and  I  applied  it  to 
his  arm.  The  letters  "Carrie"  came  out  in  bold  black  letters,  diag- 
nosing for  n:e  his  trouble,  both  as  to  the  snake  poison  and  his  girl. 
A  tourniquet  was  applied,  ana  after  a  vigorous  fight  the  young  man 
recovered. 


LECTURE  XXVIII. 


SPECIAL    WOUKDS.— Continued. 

Contusions  and  Bruises.  —  A  bruise  or  contusion  is  a  subcutaneous 
wound  inflicted  by  the  sudden  impact  of  a  blunt  body  against  the 
skin.  They  vary  in  degree  and  intensity  from  a  pinch  or  black 
eye  to  thf^  pulpiflcation  of  a  limb,  such  as  occur  in  railroad  acci- 
dents. 

Pathology. — There  is  a  breach  of  continuity  of  the  subcutaneous 
tissue,  without  injury  to  the  skin  or  mucous  membrane  covering  it. 
Blood  vessels  and  muscles  may  be  ruptured,  tissue  and  fascia 
divided,  but  the  wound  is  protected  from  external  influences  by  the 
unbroken  skin  or  mucous  membrane. 

Symptoms.  —  The  symptoms  come  on  immediately.  There  is 
always  more  or  less  shock,  being  symptomatic  in  the  case  of  a 
pinch,  but  real  in  more  severe  cases;  it  may  be  transitory  or  may 
last  a  long  time,  even  causing  death.  Pain  is  not  immediately  felt, 
the  impact  of  the  blunt  body  obtunds  the  nerves,  but  it  finally 
comes  on  and  increases  until  agony  is  endured.  It  will  subside  in 
about  an  hour,  unless  hemorrhage  is  severe  or  the  wound  is  infected, 
when  it  will  be  severe  and  lasting.  Swelling  is  always  an  accom- 
paniment, due  to  the  escape  of  plasma  into  the  tissues;  it  varies  in 
amount  nut  only  in  accordance  to  the  size  of  the  vessel  injured,  but 
as  to  whether  the  adjacent  tissue  is  loose,  when  it  will  be  great  and 
when  tight  it  wiU  not  bemnch.  Discoloration  invariably  follows, 
due  to  the  escape  of  blood  into  the  tissue,  and  the  disintegration 


126  PRINCIPLES    OF    SURGERY. 

of  the  corpuscles,  causing  the  tissues  to  be  pigmented.  The  tissues 
are  first  black,  then  a  greenish  yellow;  the  part  finally  returning 
to  its  normal  color.  The  exact  chemical  change  which  causes  th(!se 
various  colors  is  not  knovrn.  Loss  of  function  always  follow  these 
"wounds;  if  it  is  the  hand,  its  function  will  be  impaired;  if  the  eye, 
the  sight  "^vill  be  impaired,  etc. 

Diagnosis. — The  diagnosis  is  based  on  the  history  and  symptoms. 
Discoloration  is  the  most  important  diagnostic  symptom,  as  it 
shows  that  a  blood  vessel  has  been  ruptured. 

Peogxosis. — The  prognosis  depends  on  the  nature  and.  the  loca- 
tion of  the  wound.  Some  bruises  are  so  trivial  as  to  pass  un- 
noticed, while  others  are  so  severe  that  death  soon  elapses. 

Tkeatmen't. — General. — The  first  thing  to  do  is  to  combat  shock, 
using  the  remedies  of  which  you  are  familiar.  Relieve  the  pain 
with  morphia  if  it  is  severe,  or  if  not  use  some  of  the  coal  tar  pro- 
ducts, such  as  Antikamnia  or  Phenacetine.  Local. — To  hasten 
healing  cany  out  this  treatment.  Give  the  part  rest,  if  it  be  a 
hand,  put  it  in  a  sling;  if  a  leg,  place  the  patient  in  bed  and  ele- 
vate tte  limb;  elevation  is  important,  for  in  bruises  there  is  con- 
cealed hemorrhage  going  on  and  by  this  tieatraent  you  lessen  pain 
and  prevent  sucti  an  influx  of  blood  to  the  part  by  gravity.  Com- 
pression is  indicated,  but  must  be  applied  logically.  It  does  good 
by  checking  hemorrhage,  checks  excessive  transudation  and  pro- 
motes resolution  and  restoration  of  the  part  to  its  normal  condition. 
To  get  compression,  a  pad  of  cotton  and  a  roller  bandage  is  all 
that  is  necessary.  From  the  operations  you  have  witnessed,  you 
no  doubt  think  that  cotton  is  ased  extravagantly,  but  not  so,  Tve 
apply  it  net  cnlv  as  an  absorbent  and  protector,  but  also  to  obtain 
pressure;  it  is  elastic,  resilient  and  the  simplest  and  most  conve- 
nient way  to  get  compression.  If,  however,  you  feel  that  the  cotton 
is  not  sufficient,  use  a  flannel  or  rubber  bandage,  With  the  rubber 
bandage  ycu  can  get  any  amount  of  compression  you  desire.  If 
you  haven't  the  rubber  bandage  or  wish  the  bandage  to  remain  for 
a  long  time  with  access  of  air  to  the  part,  get  a  piece  of  flannel 
and  cut  it  bias  (if  you  tear  it  you  loose  the  effect  of  its  elasticty), 
and  apply  it  with  steady,  uniform  tension.  Heat  and  cold  is  use- 
ful if  applied  logically.  Cold  is  useful  when  you  have  a  hot,  in- 
flamed,   painful   wound,    but  in  using  it  you  run  the  risk  of  so  de- 


PRINCIPLES    OF    SURGERY.  127 

vitilizing  the  tissue  that  gangrene  may  result.  If  the  -wound  is  not 
very  extensive  apply  ice  bags  or  ice  water,  but  never  allow  ice  to 
come  in  contact  with  the  skin.  If  the  above  modes  are  too  severe, 
use  evaporating  lotions,  such  as  camphor,  witch  hazel  and  arnica; 
these  remedies,  although  the  old  woman's  stand-by  in  bruises,  only 
do  good  bj  their  rapid  evaporation,  due  to  their  containing  about 
90  per  cent,  of  alcohol,  their  other  uses  are  '■^nil."-  If  you  have 
to  write  a  prescription,  order  alcohol  and  color  it  with  some  bland 
drug.  Heat  is  useful,  but  remember  when  using  cold  or  heat  that 
their  affect  is  about  the  same,  and  don't  go  to  either  extreme. 
Heat  is  useful  when  the  injury  is  severe  and  gangrene  is  feared. 
You  can  use  either  dry  or  moist  heat.  A  salt  bag  is  a  good  way 
to  obtain  dry  heat,  maiie  a  salt  bag,  put  in  a  pot  and  heat  it  and 
apply  to  the  part,  or  you  use  hot  water  bags,  and  if  the  weight 
from  this  is  too  severe,  apply  hot  flannels.  Moist  heat  can  be  ob- 
tained by  the  douoh,  using  water  as  hot  as  can  be  borne;  place  the 
part  over  a  tub  and  j)our  the  water  over  it,  or  you  can  use  hot  an- 
tiseptic fomentations  applied  with  a  flannel  or  carbolized  cotton. 
A  hot  poultice  is  also  valuable.  Massage  is  also  very  valuable. 
It  is  accoraplish'^d  by  delicately  manipulating  the  thumb  on  the 
bruised  area.  It  stimulates  the  blood  flow,  and  favors  resolution 
by  breaking  up  the  blood  clots. 

BuENs  AND  Scalds.  —A  burn  is  an  injury  inflicted  by  dry  heat. 
A  scald  is  an  injury  inflicted  by  moist  heat.  Burns  and  scalds  are 
identical  in  their  pathology  and  treatment  and  will  therefore  be 
considered  together.  Most  authors  classify  these  injuries  into 
fifteen  varieties,  but  I  will  only  describe  three — burns  of  the  first, 
second  and  third  degree.  Those  of  the  first  degree  only  involves 
the  superficial  layers  of  the  skin;  in  the  second  degree,  not  oniy  is 
theepiderma  involved,  but  it  penetrates  into  the  rete  raucosura  and 
involves  the  corium.  Burns  of  the  third  degree  are  still  deeper 
and  more  destructive  than  the  former;  it  destroys  the  skin  and  in- 
volves the  subcutaneous  tissue,  muscles  and  fasdia  and  even  the 
bones  may  be  carbonized. 

Cause.  —  The  cause  is  the  application  of  intense  dry  or  moist 
heat  to  the  tissues.  The  degree  of  the  burn  depends  on  the  tem- 
perature of  the  heat  applied  and  the  duration  the  tissues  are  sub- 
jected to  it. 


128  PRINCIPLES    OF    SL'RGERY. 

Pathology.- — This  consists  in  the  destruction  of  tissue  by  coagu- 
lation of  the  albumen  of  the  cells,  followed  by  necrosis  or  gangrene. 
The  coagulation  may  not  only  be  confined  to  the  cell  albumen,  but 
may  coagulate  the  albumen  of  the  blood  in  the  vessels. 

Symptoms,  —  t^ain  is  sharp  and  excruciating  from  the  first.  The 
amount  and  character  depends  on  the  depth  and  extent  of  the  burn; 
that  is  a  hurn  of  the  first  degree,  is  much  more  painful  than  a  burn, 
of  the  third  degree,  this  is  because  the  nerves  in  burns  of  the  first 
degree  are  simply  exposed  and  irritated,  whereas  in  burns  of  the 
third  degree  the  nerves  are  destroyed.  Eedness  follows  quickly 
and  is  more  prominent  at  the  margins  of  the  burn;  this  is  due  to 
the  inhibition  of  the  vaso-constrictor  nerves  and  consequent  con- 
gestion of  the  blood  vessels.  Swelling  quickly  folio vv  burns,  and 
is  due  to  the  alteration  of  the  capillary  walls,  causing  increased 
porosity  by  enlargement  of  the  stigmata  and  stomata,  and  thus  the 
escape  of  fluid  is  reodered  easy.  The  amount  of  swelling  depends 
whether  the  tissue  injured  is  loose  or  tight.  Vesication  or  forma- 
tion of  blebs,  due  to  the  separation  of  the  layers  of  skin  and  the 
accumulation  of  serum,  is  always  seen  in  burns  of  the  first  degree, 
rarely  in  those  of  the  second  degree  and  never  in  burns  of  the  third 
degree.  Eschar  formation,  this  consists  of  the  destruction  of  a 
large  mass  of  cells,  which  die  and  are  separated  from  the  adjacent 
tissue.  The  eschar  is  sometimes  black  and  again  may  be  yellow  or 
white.  The  eschar  may  fall  off  dry,  but  if  it  becomes  infected  and 
pulpified  it  will  slough  off.  To  summarize:  Burns  of  the  first  de- 
gree are  characterized  by  hyperaemia  of  the  skin,  only  the  epiderma 
is  involved,  there  is  erythema  and  blebs  or  blisters  form.  Burns 
of  the  second  degree  are  characterized  by  the  burn,  not  only  in- 
volving the  epiderma,  but  also  the  deeper  layers  of  the  skin,  and 
there  may  be  the  formation  of  blebs  and  blisters.  Burns  of  the 
third  degree  are  characterized  by  eschar  formation  and  by  involv- 
ing the  deeper  structures  as  muscles,  etc.  There  is  usually  shock, 
which  in  bad  burns  may  be  followed  by  prostration,  delirium  and 
death.  If  the  patient  escapes  without  shock,  he  is  still  not  out  of 
danger  for  ten  days,  for  about  the  third  day,  congestion  of  some 
of  the  internal  organs  may  occur,  due  to  reflex  action,  and  jeopardize 
the  patient's  life.  And  even  ten  days  after  the  burn  there  is  dan- 
ger of  ulceration  of  the  duodenum,  which  shows  itself  as  a  bloody 


PRINCIPLES    OF    SURGERY.  129 

diarrhoea,  follo\\ed  b}"-  peritonitis.  The  pathology  of  this  ulcer  is 
obscure;  ic  is  thought  to  be  due  to  pieces  of  the  scorched  blood 
vessels  being  carried  to  the  duodeum,  causing  irritation  and  ulcera- 
tion. 

Diagnosis. — The  diagnosis  is  based  on  the  history  and  symptoms. 

Peognosis. — The  prognosis  is  based  on  the  depth  and  extent  of 
the  burn,  and  on  the  age  of  the  patient  (old  and  young  people 
stand  burns  badly).  The  depth  of  the  wound  doesn't  make  much 
difference  as  the  extent  of  surface  involved,  as  a  person  may  have 
a  leg  or  arm  burnt  off  and  recover,  but  if  the  same  person  was 
burned  over  tv\o-thirds  of  his  body,  he  would  surely  die.  The 
reason  why  people  die  who  are  burnt  over  two-thirds  of  their  body, 
is  due  either  to  increased  conduction  of  heat  from  the  body,  stop- 
page of  the  excretion  of  CO2  by  the  skin  or  to  the  stoppage  of  the 
absorption  of  O  by  the  skin.  The  first  theory  is  ra  ore  generally 
accepted. 

Teeatmbnt. — The  general  treatment  consist  of  relieving  pain 
and  combating  shock,  the  remedies  for  each  you  are  familiar  with. 
The  local  treatment  practiced  by  the  laity  and  some  physicians  is  a 
shame  and  a  crime,  a  lasting  disgrace  to  civilization.  Well  do  I 
remember,  while  a  boy  visiting  in  the  country,  when  a  playmate 
of  mine  was  burnt  by  powder;  he  was  smeared  with  soot,  molasses 
and  grease,  and  his  head  stuck  in  a  flour  barrel.  These  remedies 
are  used  because  they  stop  the  pain  by  excluding  the  air  from  the 
wound,  but  this  can  be  accomplished  without  using  these  infected, 
dirty  remedies.  J^ever  use  Carron  oil.  This  filthy  mixture  has 
long  been  in  use;  its  name  being  derived  by  its  being  discovered 
by  a  surgeon  to  a  large  iron  factory  in  Carron,  England,  where 
burns  were  of  daily  occurrence.  It  is  true,  it  stops  the  pain  by 
excluding  the  air,  but  it  is  one  of  the  best  culture  medias  I  know 
of.  Dress  the  hand  so  as  to  exclude  air  and  prevent  infection,  and 
the  wound  will  heal  under  one  dressing.  Render  the  part  clean, 
and  if  necessary  to  accomplish  it,  give  an  ansesthetic.  Clip  away 
all  fragments  of  skin,  remove  all  dirt  and  cloth,  wash  it  in  green 
soap,  alcohol  and  a  bi-chloride  solution,  if  the  surface  is  small,  but 
if  large  use  a  n on- toxic  antiseptic  as  boracic  acid,  acetate  of  alumi- 
num, etc.,  dust  with  one  of  the  numerous  antiseptic  powders,  of 
which    iodoform  is  the  best,  apply  a  piece   of  gauze,  then  a  thick 

9 


130  PRINCIPLES    OF    SURGERY. 

layer  of  cotton,  a  fold  of  oil  silk  over  this  and  lastly  a  neat  band- 
agre.  This  dressino:  can  usually  stay  on  until  healmo:  occurs.  In 
addition  to  the  above,  you  must  prevent  defornaity  by  means  of 
splints  after  putting  the  part  in  its  anatomical  position.  If  neces- 
sary assist  healing  by  skin  grafting. 


LECTURB  XXIX. 


IIS'FLUENCE  OF  CONSTITUTIONAL  CONDITIONS  UPON 

INJURIES. 

The  subject  which  \\e  will  now  discuss  is  one  of  great  ircport- 
ance,  and  is  generally  not  included  in  text-books.  It  is  the  sub- 
ject of  considering  the  general  health  of  a  patient,  which  should 
influence  you  in  deciding  to  operate  and  its  influence  in  the  conva- 
lescent stage  after  the  operation.  Sir  James  Padgett  says  that  be- 
fore performing  the  most  trivial  operation,  you  should  first  consider 
the  danger  to  v^our  patient  and  should  examine  him  at  least  as  care- 
fully as  you  would  for  life  insurance,  where  only  a  few  thousand 
dollars  are  involvled,  whereas  in  the  former  case  there  is  a  life  at 
stake.  The  importance  of  this  subject  is  aptly  illustrated  by  the 
common  remark  often  of  late  noticed  in  the  newspapers  in  writing 
up  a  death  notice  of  a  man  w^ho  has  been  operated  on,  it  is  stated 
very  satirically  that  the  "operation  was  a  success,  but  the  patient 
died."  It  is  true  that  some  patients  do  not  die  from  the  opera- 
tion, for  that  in  its  technique  was  a  success,  but  they  die  fi-om  some 
constitutional  condition,  some  accompanying  but  unnoticed  trouble 
which  crops  out  and  kills  the  patients  after  a  successful  operation. 
There  are,  of  course,  some  operations  of  such  necessity  that  you 
are  justifiable  in  not  considering  the  patient's  health,  such  as 
strangulated  hernia,  progressive  gangrene,  etc.,  but  there  are 
others,  such  as  decorating  surgery,  such  as  removing  a  deformity 
or  dissecticg  out  a  scar,  of  which  little  thought  is  given,  and  just 
ouch  operations  are  sonietimes  attended  by  serious  consequences, 
all  from  the  lack  of  cousidering  the  patient's  general  health  before 


PRINCIPLES    OP    SURGERY.  131 

operating.  So  before  operating  the  following  conditions  should  be 
looked  into: 

Age. — Children  under  five  years  of  age  stand  surgery  badly. 
This  statement  is  the  conclusion  of  many  surgeons  of  long  experi- 
ence. They  stand  shock  badly,  have  little  resisting  power  to  loss 
of  blood,  can't  be  kept  quiet  and  stand  anaesthesia  badly.  So 
avoid  operating  on  a  child  if  possible.  A  person  between  five  and 
fifteen  is  the  best  patient  a  surgeon  can  have.  They  stand  shock 
well,  their  organs  are  in  good  working  order  and  free  frona  func- 
tional diseases,  their  mind  is  in  a  tranquil  state,  being  not  worried 
about  business  or  the  future.  From  fifteen  to  forty  the  danger 
increases,  and  from  forty  to  seventy  it  rapidly  increases,  as  the 
patients  are  depressed,  anxious  in  regard  to  the  future,  their  or- 
gans are  diseased,  and  everything  looks  gloomy.  Old  people  may 
be  divided,  however,  into  four  classes.  The  first  class  are  those 
who  are  fat,  pale  and  flabby,  they  are  lazy  and  indolent,  witti  a 
weak  pulse;  this  class  is  a  poor  one  for  surgery  aod  can't  stand 
much  operative  interferences.  The  second  class  are  those  who  are 
fat,  hard}^  and  vigorous.  They  sleep  well,  eat  hardily  and  take 
plenty  of  exercise,  they  are  ruddy,  strong  and  healthy;  these 
people  are  better  by  far  for  surgical  workthau  the  first  class.  The 
third  class  are  those  who  are  dried  up,  Aviry,  tough,  vigorous  and 
are  active  busy  bodies;  these  take  surgery  best  ot  an}^  class  of  old 
peoole.  The  fourth  class  are  those  who  are  dried  up,  shriveled, 
becrippled  "en  toto,"  who  have  a  weak  pulse,  a  bad  digestion  and 
are  anemic;  this  is  the  vvorst  class  of  all  for  surgery.  In  opera- 
ting on  an  old  person,  do  as  little  cutting  as  possible,  guard  against 
loss  of  blood  and  shock,  keep  him  wslyio.  and,  above  all,  do  not 
feed  him   too  mach,  they  can't  stand  as  much  food  as  the  young. 

Sex. — As  a  general  rule  women  stand  surgery  better  than  men. 
This  is  because  women  ace  not  as  liable  to  constitutional  diseases 
as  men,  such  as  syphilis;  they  do  not  indulge  so  much  in  alcoholic 
drinks  and  are  not  su  restless,  they  are  used  to  being  housed  up. 
ISTever  operate  on  women  during  the  menstrual  period,  unless  actu- 
ally necessary,  f^r  from  some  unaccountable  cause  there  will  be 
fever  and  irritability.  Never  operate  on  pregnant  wore  en,  unless 
there  is  a  large  ovarian  tumor  or  a  hernia,  for  fear  of  the  compli- 
cation of  abortion.     It  is  also  best  not  to  operate  during  lactation, 


132  PRINCIPLES    OF    SURGERY. 

although  the  patients  usually  do  well.  Under  no  circumstances 
must  you  operate  on  the  mamma  during  lactation,  as  hemorrhage 
■will  be  se\'ere,  hard  to  stop  and  sinuses  will  be  opened  up  through 
which  milk  will  escape  and  thus  retard  healing. 

YiGOE  AND  Weakness. — It  is  not  the  strong,  robust  man  that 
makes  the  best  patient.  They  may  look  ruddy  and  say  they  have 
the  constitution  of  an  ox,  but  their  convalescence  is  not  as  satis- 
factory as  the  pale,  weak  patient.  This  is  because  a  man  used  to 
hard  work,  gross  food  and  outdoor  life,  v^hen  operated  on,  the 
change  of  life,  dread  of  the  fulure  and  shock  often  kills  him. 
"While  a  pale,  weak  man,  who  has  been  lying  in  the  hospital  for 
months  and  looks  on  the  operation  as  the  only  means  of  saving  his 
life,  will  do  well  and  make  a  speedy  recovery. 

OsEsriY  AND  Plethoka.  — Obesiiy  is  a  bad  complication.  Some- 
times a  fat  man  will  make  a  good  patient,  provided  he  is  3^oung 
and  the  fat  is  hereditary.  But  when  seen  in  a  man  over  forty,  it 
is  due  to  laziness  and  he  will  be  a  hard  patient  to  manage.  He  is 
an  elephant  on  your  hands,  can^t  be  shifted  on  the  bed,  can't  be 
kept  clean  and  bed  sores  will  form.  When  an  incision  is  made 
through  the  skin  of  a  fat  man,  it  will  be  found  thin  from  pressure; 
you  can't  approximate  the  wound,  you  can't  get  compression  and 
the  fatty  tissue  is  liable  to  break  down  and  become  necrotic. 
Plethora  is  not  a  contraindication  to  surgery.  They  generally  do 
well,  unless  the  plethora  be  from  organic  disease.  Do  not  get  a 
plethoric  individual  mixed  with  a  man  like  a  beer  wagon  driver  or 
an  inn  keeper,  whose  full  bloodedness  is  clue  to  organic  disease 
caused  by  alcohol;  these  people  are  horrible  subjects. 

Alcoholism.—  A  patient  addicted  to  alcohol  is  the  worse  subject 
a  surgeon  has  to  deal  with;  there  can  be  no  complication  as  bad. 
J^ever  operate  on  a  habitual  arunkard,  unless  actually  necessary,  as 
for  appendicitis  or  hernia.  The  operation  on  such  subjects  is 
usually  followed  by  delirium  tremens  and  results  fatally.  Opium 
is  almost  as  great  a  barrier  to  surgery  as  alcohol.  The}"  are  in  the 
habit  of  quieting  their  nerves  by  opium,  and  after  the  operation 
are  compelled  to  have  it  and  in  larger  doses.  It  locks  up  the 
bowels  and  does  great  harm,  especially  after  laparotomies. 

Tuberculosis. — Tubercular  patients,  unless  the  disease  has  at- 
tacked the  lungs  or  liver,  do  well  after  an  operation.     Tuberculo- 


PRINCIPLES    OF    SURGERY.  133 

sis  of  a  bone  or  gland  does  not  indicate  adversely  in  deciding  to 
operate;  they  stand  ibe  operating  well,  but  the  recovery  is  slow. 
If  you  do  not  remove  ev^ery  particle  of  tubercular  roatter,  the  dis- 
ease will  return  before  the  wound  heals.  You  can't  count  on  a 
cure  until  three  months  has  elapsed.  The  operation  has  to  be  fre- 
quently performed  over.  When  the  disease  has  attacked  the  lungs 
or  liver,  you  must  give  the  case  serious  consideration  before 
operating,  for  in  the  case  of  the  lungs,  the  anfesthetic  adds  to  the 
trouble,  and  pneumonia  may  follow  the  operation.  In  the  case  of 
the  liver  or  bowels,  serious  complications  may  arise,  so  do  not 
operate  unless  the  life  of  the  patient  depends  on  it.  One-fourth  of 
the  phthisical  patients  sufPer  from  "fistula  in  ano;"  they  cough  up 
the  sputum,  it  goes  down  the  throat,  through  the  alimentary  canal 
and  produces  a  fistula.  If  a  man  comBs  to  you  pale,  emaciated, 
having  fever  and  debilitating  sweats  and  tells  you  the  consumption 
is  bad  enough  and  asks  you  to  relieve  him  of  the  pain  of  the  fistula, 
I  believe  it  is  your  duty  to  operate;  at  the  best  he  caa't  live  long, 
and  you  are  justifiable  in  making  him  comfortable  for  this  short 
while,  even  at  the  risk  of  his  immediate  death.  In  performing  this 
operation  do  it  quickly,  give  the  angesthetic  to  its  minimum  extent, 
split  open  the  fistula,  irrigate  and  pack  with  gauze. 

Syphilis. — It  is  commonly  thought  that  syphilis  prevents  a 
wound  from  healings  but  my  experience,  having  operated  time  and 
time  again  in  the  acate  stage,  teaches  me  that  this  is  not  so,  the 
wounds  heal  well.  It  is  not  a  very  agreeable  job,  for  there  is  dan- 
ger of  the  surgeon  contracting  the  disease,  but  the  wound  made 
heals  kindly,  aud  as  far  as  the  patient  is  concerned  he  is  not 
worsted,  but  many  surgeons  to-day  are  suffering  from  syphilis 
contracted  while  operating  on  S3^philitic  patients. 

Eheumatism  a^'d  Gout. — ISTeither  of  these  diseases  retard  the 
healing  of  wounds.  A  man  suffering  from  either  makes  a  good 
subject,  but  it  is  best  not  to  add  the  pain  of  an  operation  to  the 
pain  of  an  acute  attack  of  rheumatism,  you  should  postpone  the 
operation  if  possible.  Often  when  there  is  a  tendency  to  these 
diseases,  an  operation  will  precipitate  an  attack,  so  don't  be  sur- 
prised when  this  happens. 

Caxcer, — A  patient  suffering  from  a  cancer  makes  a  good  sub- 
ject; the  wound  heals  readily.  Cancer  is  not  inoculable,  so  there 
is  no  danger  from  cutting  yourself  while  operating. 


134  PRI^'CIPLES    OF    SURGERY. 

Anemia.  — This  coDclition.  should  be  corrected  if  possible  before 
operating,  by  the  administration  of  tonics,  iron,  etc.  If  the  ane- 
mia is  due  to  hemorrhage,  as  from  a  fibroid  tumor  or  menorrhagia, 
don't  v^ait  for  medicines.  In  the  case  of  the  tumor  remove  it  at 
once. 

Leuoocythemia. — This  disease  absolutely  prohibits  any  surgical 
interference.  Out  of  one  hundred  cases  ^here  Splenectomy  was 
performed  for  this  disease,  all  died. 

Hemophilia.  -This  is  a  constitutional  disease,  characterized  by 
the  individual  bleeding  enormously  from  trivial  injuries.  Never 
operate  on  these  individuals  if  possible  to  avoid  it.  Sometimes 
they  \Yill  fool  you;  they  may  have  bled  profusely  on  several  occa- 
sions, and  their  ancestors  ha\e  died  from  the  disease;  yet  ^  lien 
operated  on  they  do  well  and  bleed  very  little. 

Malaria. — This  disease  has  a  curious  influence  upon  results. 
]^ot  only  does  malaria  influence  the  wound,  but  the  wound  influ- 
ences malaria.  A  patient  suffering  from  chills  and  fever  is  made 
much  worse  by  an  operation;  or  if  a  patient  had  chills  and  fever 
fifteen  years  before,  on  operating  upon  him,  the  chills  and  fever 
will  return  and  in  much  more  serious  form.  A  man  may  have  lived 
in  a  malarial  district,  but  never  was  afl'ecled  ^vith  the  disease,  or  may 
have  lived  elsewhere  for  years,  but  v^hen  operated  on  it  will  break 
out,  the  germs  having  been  lurking  in  his  system  ever  since  he  lived 
in  the  malarial  district.  There  is  often  periodical  trouble  from  a 
wound  due  to  malaria;  the  wound  will  bleed  every  other  day,  rea- 
dens  every  other  day  and  suppurates  every  fourth,  seventh  or 
t~Yenty-first  day.      Give  quinine  and  these  symptoms  wiU  disappear. 

Acute  Diseases. — Never  operate  during  acute  disease,  such  as 
the  Lagrippe.  scarlet  fe^er,  mumps,  chicken  pox,  etc.,  unless  actu- 
ally necessary  to  save  life. 

Affections  of  the  NEEvors  System. — There  are  certain  types  of 
individuals  who  comes  to  the  doctors  offlce  that  he  can  size  up,  he 
has  a  nervous  tremor,  timid  and  effiminate;  he  discusses  the  opera- 
tion with  terror  add  horror.  Don't  think  he  will  make  a  bad  sub- 
ject, after  the  operation  he  makes  the  bravest  and  most  hopeful 
patient  and  soon  recovers.  The  ^orst  patients  are  the  morose  and 
sullen;  no  matter  what  encouragement  you  give  them,  and  bright 
accounts  of  the  operation,  she  will  sigh  and  say,  "I  am  ready  to 


PRINCIPLES    OF    SURGERY.  135 

go  when  the  Lord  calls  rae."  Get  the  coufidence  of  your  patients, 
never  attend  a  case  over  twice  without  having  gained  some  influ- 
ence over  the  patient;  if  you  can't  do  it  by  winning  their  affec- 
tions, make  them  afraid  of  you.  Insane  people  make  good  sub- 
jects, unless  they  are  dirty  in  their  habits  and  uncontrollable.  A 
patient  who  has  teen  to  an  asylum,  kept  clean,  had  good  food  and 
deprived  of  alcohol,  makes  a  splendid  subject  for  operative 
measures. 

DiAnETES.-  —This  is  a  disease  characterized  by  sugar  in  the  urine. 
How  or  why  it  is  there  we  do  not  know;  some  observers  claim  it 
is  caused  by  irritation  of  the  medulla,  others  say  it  is  due  to  dis- 
ease of  the  liver.  However  this  may  be,  we  do  know  that  a 
wound  made  on  a  patient  suffering  from  the  disease  \vill  not  heal, 
but  is  liable  to  slough  or  become  gangrenous.  Examine  the  urine 
every  time  before  operating,  and  if  sugar  is  found,  don't  operate, 
unless  the  urgenc}'-  is  so  great  that  the  risk  is  justifiable. 

YiscERAE  Diseases. — Every  patient  that  comes  t)  you  will  have 
a  weak  heart  and  can't  take  chloroform.  They  all  have  a  "Locus 
Minoris  Resistentije"  in  their  chest.  It  is  the  people  who  know 
there  is  nothing  the  matter  with  their  heart  who  die  from  chloro- 
form anaesthesia.  I  have  used  anesthetics  in  patients  with  almost 
every  disease  of  the  heart  without  ill  effect.  Patients  who  are  sup- 
posed to  be  diseased  to  such  a  degree  as  to  contraindicate  chloro- 
form stood  it  well  and  the  wound  heals  readily.  In  phlebitis, 
artheromatous  or  calcareous  degeneration  of  the  vessels,  the  result 
is  markedly  influenced;  there  is  always  danger  of  secondary  heraor- 
rliage  and  the  flaps  may  become  gangrenous  from  improper  nutri- 
tion. In  diseases  of  the  respiratory  tract,  such  as  bronchitis  or 
pneumonia,  chloroform  should  be  carefully  given  if  at  all.  Diseases 
of  the  stomach  and  alimentary  canal  often  complicate  results,  the 
patient  wiil  be  unable  to  assimulate  food,  and  convalescence  will 
be  retarded.  Constipation  also  influences  results.  Some  diseases 
of  the  liver  is  a  bad  complication,  such  as  torpor,  cirrhosis,  fatty 
and  lardaceous  degeneration.  Diseases  of  the  kianey,  such  as 
Bright's  disease  and  surgical  kidney,  is  a  positive  barrier  against 
surgerv,  other  than  pressing  operations  to  save  life.  Albumen  in 
the  urine  is  a  barrier,  the  wound  will  heal  well,  but  the  patient 
will  die  from  uremic  poison. 


136  PRINCIPLES    OF    SURGERY. 


LECTURE  XXX, 


ANTHE  AX— H  Y  DKOPHOB  [A. 

Anthrax,  Malignant  Pustules,  or  Wool  Sorters  Disease,  is  an 
acute,  infectious  disease,  due  to  the  inoculation  of  a  specific  mi- 
crobe. It  is  characterized  by  local  inflammation  and  afterwards  by 
general  infection  of  the  \^!hole  body,  and  usually  results  in  death. 
This  disease  is  particularl}''  interesting,  because  of  its  being  the  first 
disease  to  be  proven  to  be  of  microbic  origin.  Pollender,  in  1849, 
with  the  crude  instruments  then  is  use,  proved  it  to  be  due  to  a 
microbe  and  named  it  the  Bacillus  Anthracis.  It  is  the  largest 
pathogenic  germ  known,  being  from  five  to  ten  microns  in  length 
and  from  one  to  one  and  a  quarter  microns  in  diameter.  It  is  a 
rod-shaped  germ,  extremely  hardy,  grows  at  ordinary  tempera- 
tures, but  grows  test  at  the  temperature  of  the  body.  It  grows 
in  most  all  the  medias,  can  be  stained  easily  by  aniline  dyes,  mul- 
tiplies in  the  living  body  by  direct  segmentation,  and  when  culti- 
vated in  the  laboratory  ic  multiplies  by  spore  formation.  Anthrax 
never  occurs  spontaneously  in  man,  but  occurs  primarily  in  the 
lower  animals  and  from  them  are  communicated  to  man.  The 
bacillus  is  found  in  low,  swampy  places  in  warm  countries,  and  is 
transmitted  to  animals  by  grazing  the  grass  on  these  swamps.  It 
usually  attacks  herbivora,  less  so  the  omnivora  and  never  attacks 
the  carnivora.  The  germ  locates  in  the  lips,  mouth  or  stomach, 
produces  the  disease  and  usually  kills.  The  disease  is  transmitted 
to  man  by  handling  the  hides  or  meat  of  these  animals.  It  is 
usually  seen  in  tanners,  butchers  and  wool  sorters.  Anthrax  may 
be  internal  or  external.  Internal  anthrax  is  contracted  through 
the  respiratory  or  alimentary  tract  and  belongs  to  the  physician  to 
treat.  External  anthrax  is  contracted  through  the  skin  and  be- 
longs to  the  surgeon,  this  form  we  will  now  discuss.  External 
anthrax  is  due  to  infection  through  the  skin,  and  as  the  unbroken 
skin  acts  as  a  barrier  against  infection,  there  must  be  an  "'mfection 
atrium,^''  as  in  wool  sorters  a  hang  nail  is  sufficient  to  allow  the 
entrance  of  the  germ.     After  penetrating  the  skin  and  reaching  Ihe 


PRINCIPLES    OF    SURGERY.  137 

deeper  tissues,  the  germ  may  produce  either  an  anthrax  carbuncle 
or  anthrax  o3dema,  which  depends  on  the  character  of  the  tissue 
reached.  If  the  tissues  are  firm,  dense  and  vascular  a  carbuncle 
■^ill  result.  If  the  tissues  are  loose  and  poorly  supplied  with  blood, 
anthrax  oedema  Avill  result.  The  pathology  of  both  carbuncle  and 
oedema  are  the  same,  if  it  attacks  the  face  anthrax  carbuncle  a\  ill 
lesult;  if  it  attacks  the  forearm  or  back,  anthrax  oedema  will  re- 
sult. 

Symptoms.  —The  symptoms  of  anthrax  carbuncle  usually  comes 
on  in  from  six  to  twenty-four  hours  after  inoculation.  There  is 
local  tingling,  burning,  itching  and  redness,  with  the  formation  of 
a  blister,  which  is  filled  with  serum,  it  soon  becomes  black  and 
bursts,  exposing  a  small  spot  of  devitilized  tissue,  which  continues 
to  grow,  and  in  a  few  hours  is  as  large  as  a  dollar.  This  is  sur- 
rounded by  a  hard,  inflammatory  base.  The  disease  gradually  ex- 
tends into  the  neighboring  tissue,  and  septic  phlebitis  or  lymphan- 
gitis may  result.  The  pulse  is  rapid,  skin  cold  and  clammy  and 
there  are  general  symptoms  of  septic  intoxication.  The  symp- 
toms in  anthrax  oedema  are  not  so  well  marked  or  so  easily 
differentiated  from  other  troubles.  There  is  localized  tino^lino;, 
smarting  and  redness,  the  swelling  and  oedema  then  rapidly  spreads 
in  all  directions.  The  tissues  are  infiltrated  with  bloody  serum 
and  death  usualh  results. 

Diagnosis. — The  diagnosis  is  based  on  the  history,  the  fact  of 
working  in  a  tannery  or  as  a  butcher  or  a  wool  sorter.  The  rr  icro- 
scope  gives  a  positive  diagnosis.  The  disease  can  be  differentiated 
'from  the  ordinary  carbuncle,  by  the  fact  that  an  ordi-nary  suppu- 
rating carbuncle  is  nothing  but  a  mass  of  furuncles  and  each  dis- 
charges from  a  separate  opening,  ^'^hereas  in  anthrax  carbuncle 
there  is  a  single  opening,  and  it  has  a  characteristic  gangrenous 
scar  beneath. 

Pkogxosis. — The  prognosis  is  very  grave.  It  is  based  on  the 
location,  character  of  the  trouble  and  on  the  constitution  of  the 
patient.  The  carbiincular  variety  gives  a  better  prognosis  than 
the  oedematous  variety. 

Treatment. — The  local  treatment  is  the  most  important.  Pa- 
renchymatous injections  of  carbolic  acid  is  recommended,  thoroughly 
saturate  the  tissues,  using  a  o  or  10  per  cent,  solution.     Introduce 


138  PRINCIPLES    OF    SURGERY. 

the  needle  about  a  quarter  of  an  inch  from  the  diseased  tissue  and 
make  numerous  punctures  all  around  the  wound.  If  there  is  no 
improvement  in  six  hours,  repeat  (he  operation.  Guard  against 
poisonino-  the  patient  with  the  acid.  If  this  treatment  does  no 
good,  apply  a  tourniquet,  render  the  part  clean  aud  excise  the  dis- 
eased tissue,  irrigate  with  a  bi-chloride  solutioa,  cauterize  the 
wouad  and  pack  with  iodoform;  dress  the  wound  daily.  Remem- 
ber that  death  threatens  from  depression,  and  give  stimulants  and 
good  nutritious  food. 

HYDROPHOBIA,  Rabies,  Canine  Madness  or  Lyssa  are  terms 
used  to  designate  an  infectious  disease  caused  Ly  the  bite  of  a 
rabid  animal.  The  essential  cause  is  not  known,  several  germs 
have  been  found  associated  with  the  disease,  but  none  of  them 
have  been  proven  to  cause  the  disease.  We  do  know,  however, 
that  the  poison  comes  from  the  salivary  glands  of  animals  belong- 
ing to  the  canine  tribe,  dogs,  cats,  wolves  and  foxes. 

Hydeophobia  in  Dogs. — The  term  hydrophobia,  when  applied  to 
the  disease  in  dogs,  is  a  misnomer.  The  word  means  a  dread  of 
water,  and  a  dog  suffering  from  the  disease  is  not  afraid  of  water, 
but  drinks  hardily  in  the  first  stage  and  even  in  the  last  stages  at- 
tempts to  swallow  water  when  given  tohinc.  The  old  test  of  plac- 
ing a  bucket  of  water  before  the  dog  and  if  he  refuses  to  drink,  to 
pronounce  him  mad,  is  no  good.     The  proper  name  is  rabies. 

Symptoms.-  The  symptoms  are  in  three  stagei:  First,  premoni- 
tor}';  second,  irritability;  third,  paralj^sis.  I  do  not  believe  rabies 
can  originate  in  a  dog  spontaneously ,  he  must  be  bitten  by  a  dog 
or  other  animal  suffering  from  the  disease.  After  having  been 
bitten,  a  variable  period  of  incubation  elapses,  which  may  be  froro 
ten  days  to  six  months;  the  usual  period  is  about  four  weeks.  A 
dog  having  been  bitten  about  four  weeks  before,  the  woand  having 
perfectly  healed,  the  dog  becomes  morose  and  sullen.  His  v\hole 
nature  is  changed,  the  former  like  for  his  master  is  changed  to 
dislike,  when  called' to  his  meals,  he  refuses  to  come,  sulks  behind 
the  house  and  v\  hen  caught  snaps  at  you ;  again ,  the  dog  may  become 
more  extravagant  in  his  affections,  and  if  you  have  a  sore  on  your 
hand  you  are  liable  to  be  inoculatea  by  his  licking  you;  these  are 
the  prodromal  symptoms.  After  three  or  four  days  the  irritative 
stage  comes  on.     The  dog  is  taken  with  a  desire  to  roam  about,  an 


PRINCIPLES    OF    SURGERY.  139 

irresistible  impulse  makes  him  travel.  His  bead  and  tail  is 
drooped,  eyes  extremely  red.  and  if  another  dog  crosses  his  path 
there  will  be  a  fight.  He  makes  no  attempt  to  bite  a  man  when 
he  meets  him  unless  the  man  trys  to  stop  him.  If  he  is  put  in  a 
cage  he  will  bite  the  iron  rods  in  his  frenzy.  Soon  this  stage 
passes  off  and  the  stage  of  paralysis  comes  on.  His  hmd  legs  be- 
come paralyzed,  he  is  worn  out  from  ^a  ant  of  food  and  from  long 
travel,  and  curls  up  in  a  fence  corner  and  dies.  This  generally 
takes  place  in  from  four  days  to  two  v\eeks. 

Hydrophobia  in  Man.  —  Its  frequency  varies,  some  sensible  and 
competent  observers  claim  there  is  no  such  disease  and  have  offered 
large  rewards  for  the  exhibition  of  a  case;  others  equally  as  com- 
petent claim  there  is  such  a  disease,  but  deny  its  frequency.  Thirty 
cases  have  been  in  the  last  year  reported  from  the  United  States 
and  France. 

Cause.- — The  cause  is  the  bite  of  a  rabid  animal. 

Symptoms. — A  man  having  been  bitten  by  a  dog,  is  in  a  state  of 
terror  for  a  week  or  more,  but  as  time  defaces  the  accident  he 
thinks  no  more  about  it.  In  about  six  weeks,  which  is  the  usual 
period  of  incubation,  although  it  has  been  known  to  be  as  long  as 
eleven  months,  the  prodromal  symptoms  appear.  There  is  pain 
about  the  old  wound,  which  has  healed,  but  now  becomes  red  and 
throbbing.  He  is  irritable,  cross,  depressed,  has  forebodings  of 
evil  and  says  he  is  going  to  die.  After  a  few  days  more  active 
symptoms  develop,  there  is  a  constricted  feeling  about  the  throat, 
he  is  unable  to  swallow  and  although  suffering  from  intense  thirst 
he  dreads  water;  if  a  glass  of  \^ater  is  handed  him  he  will  attempt 
to  drink  it  and  will  be  almost  thrown  into  convulsion  and  will  re- 
fuse it  thereafter.  There  is  oppression  about  the  chest,  the  respira- 
tion is  interfered  with,  not  as  in  tetanus  by  rigidity  of  the  pectoral 
muscles,  but  by  spasms,  and  constriction  of  the  glottis.  The  most 
horrible  symptom  is  the  terror  of  the  patient,  the  despair  and  hope- 
lessness is  appalling  to  the  doctor.  Nothing  yo'u  can  say  gives  hina 
any  comfort  or  removes  the  depression.  The  temperature  runs  up 
to  lUl-103-lOG  degrees  F. ,  pulse  rapid  and  feeble.  Kature  is  not 
as  merciful  in  this  disease  as  in  others,  his  brain  remains  clear  to 
the  last  and  he  suffers  horribly.  Death  invariabl3^  occurs  m  from 
four  to  seven  days  from  the  pain,  starvation  and  depression  of  the 


140  PRINCIPLES    OF    SURGERY. 

heart.  You  ba've  no  doubt  heard  that  a  man  with  hydrophobia 
simulates  a  dog,  it  is  unfounded,  the  i^-enom  which  produces  the 
trouble  has  no  power  of  changing  a  n^an  into  a  dog.  The  patient 
does  make  a  noise  like  the  bark  of  a  dog,  but  it  is  caused  by  his 
efforts  to  expel  mucous  from  his  throat.  And  the  intense  pain 
causes  him  to  throw  himself  from  the  bed  and  roll  on  the  floor. 

Diagnosis, — The  diagnosis  is  based  on  the  history.  The  fact  of 
having  been  bitten  by  a  dog,  and  the  chracteristic  throat  symptoms 
makes  the  diagnosis  clear.  It  can  be  differentiated  from  tetanus 
by  the  fact  that  the  jaws  are  not  locked,  and  from  the  respirations 
being  interfered  with,  not  as  in  tetanus  by  spasms  of  the  pectoral 
muscles  and  diaphragm,  but  by  spasms  of  the  glottis. 

Prognosis. — The  prognosis  depends  on  the  stage  you  see  the 
patient  in.  If  he  has  just  been  bitten  by  heroic  treatment  there  is 
a  chance  of  recovery,  but  if  the  disease  has  already  made  its  ap- 
pearance, he  wall  die  regardless  of  treatment. 

Teeatment. — The  prophylactic  treatment  is  the  only  treatment 
wbich  gives  any  hope.  Some  individuals  escape  hydrophobia  when 
bitten  by  rabid  animals,  this  is  explained  by  their  being  bitten 
through  their  clothes,  and  the  virus  is  wij)ed  off  by  them,  but  it  is 
your  duty  to  treat  the  v\ound  heroically  under  all  circumstances 
and  risk  nothing  to  chance.  Apph^  a  tourniquet  as  quickly  as 
possible,  split  the  wound  wide  open,  either  remove  the  virus  by 
•sucking  it  or  with  the  cupping  glass,  cauterize  the  wound,  using 
the  actual  cautery  (never  use  nitrate  of  silver,  as  it  does  net  pene- 
trate deep  enough),  use  the  therm o-cautery,  a  red  hot  iron  or  pure 
nitric  acid.  After  devoting  your  first  attention  to  the  patient, 
look  for  the  dog.  When  you  find  him  don't  kill  him,  put  him  in 
a  cage  and  v/ait  for  developn  ents,  he  may  have  worms  aod  will 
simulate  rabies,  but  will  recover  in  a  few  days;  but  if  the  dog  dies 
w^lth  all  the  symptoms  of  rabies,  send  your  patient  to  Pasteur's 
Institute  for  treatment  by  his  serum  at  once.  The  mode  of  pre- 
paration of  this  serum  has  been  explained.  Tbe  success  of  this 
treatment  is  without  doubt.  If  you  do  not  see  the  patient  until 
the  disease  has  fully  developed,  don"t  teli  him  he  has  hydrophobia, 
he  has  troubles  enough  of  his  own,  put  him  in  bed  and  adrcinister 
morphine  and  chloroform  until  death  relieves  him  of  his  sufferings. 


PRINCIPLES    OF    SURGERY.  141 


LECTURE    XXXI, 


GLANDERS— ACTINOMYCOSIS. 

Glanders,  Farcy  or  Eqtjinia  is  a  constitutionai  disease  due  to 
the  infection  of  the  bacillus  mallei.  The  disease  never  primarily 
affects  man,  but  is  transmitted  to  him  secondarily  from  animals. 

Cause. — The  essential  cause  is  a  germ  known  as  the  Bacillus 
Mallei.  It  is  a  rod-shaped  bacillus,  m  length  about  two-thirds  the 
diameter  of  a  red  corpuscle  and  about  one-third  its  diameter  in 
breadth.  It  is  about  the  size  of  the  bacillus  tuberculosis,  it  is  im- 
mobile, multiplies  by  spore  formation,  grows  in  most  of  the  com- 
mon culture  medias,  develops  best  at  about  the  temperature  of  the 
body,  stains  readily  with  aniline  dyes  and  is  very  resisting  to 
germicides  and  heat. 

Pathology. — A  horse,  when  he  acquires  glanders,  has  the  ap- 
pearance of  having  a  bad  cold.  His  temperature  per  rectum  will 
be  from  a  108-109  degrees  F.,  he  is  restless,  irritable,  coughs,  dis- 
charges flow  from  the  nose,  nostrils  are  swollen  and  their  mucous 
membranes  are  purplish  in  color.  In  a  sh^rt  while  the  mucous 
membrane  becomes  spotted  with  red  punctiform  points,  which 
increase  in  size  aad  finally  ruptures  and  pours  out  a  nasty,  fetid  dis- 
charge. If  this  discharge  comes  in  contact  Vvitli  the  broken  skin 
of  man,  the  disease  is  acquired  and  usually  results  fatally.  It  is 
more  common  among  grooms,  hostlers  and  jockeys.  The  disease 
cannot  occur  without  an  ^Htifection  atrittm.'''' 

Symptoms,. — When  inoculation  occurs,  say  in  a  hostler,  there  is 
a  period  of  incubation  varying  from  two  days  to  six  weeks.  After 
this  time  elapses  the  ])rodroraal  symptoms  appear.  There  is  ano- 
rexia, nausea,  headache  and  fever,  the  wound,  which  has  not 
healed  from  being  contaminated  by  dirty  bandages,  is  swollen,  con- 
gested and  gangrenous.  The  bacillus  produces  a  chronic  inflam- 
mation, which  is  attended  by  increased  formation  of  embryonal 
cells,  these  become  massed  together  causing  pressure,  and  an  ulcer 
is  formed,  which  progresses  rapidly;  if  it  is  on  the  face,  its  whole 
surface  becomes  involved;  if  on  the  hand,  the  bones  may  even  be 


142  PRINCIPLES    OF    SURGERY. 

attacked.  The  ccnstitutional  symptoms  now  become  worse,  there 
is  a  severe  chill,  high  fever,  prostration,  collapse  and  death. 
Glanders  is  sometimes  said  to  be  acute  or  chronic.  The  acute 
variety  is  due  to  a  germ  of  great  virulenc}'"  acting  on  tissues  of 
low  resisting  power  and  is  always  fatal.  Chronic  glanders  is 
due  to  an  attenuated  germ  or  virus  acting  on  tissues  of  high  re- 
sisting power,  and  there  is  a  chance  of  recovery.  The  symptoms 
of  both  varieties  are  the  same,  only  differing  in  intensit3^ 

DiAONosis.  ■ — The  diagnosis  is  based  on  the  occupation  of  the 
patient,  on  the  symptoms  and  by  examining  the  secretions  under 
the  microscope  and  finding  the  bacillus  mallei,  makes  the  diagnosis 
positive.  If  you  are  in  the  country  where  there  is  no  microscopist, 
you  can  make  your  diagnosis  by  inoculating  an  animal  with  the 
secretions,  when  if  the  disease  is  glanders,  the  animal  w  ill  die  in 
four  days  with  all  the  symptoms  of  the  disease. 

Prognosis. — The  prognosis  depends  on  the  health,  vigor  and 
robustness  of  the  patient,  on  the  character  of  the  attack,  whether 
acute  or  chronic,  on  your  early  diagnosis,  your  knowledge  of  the 
pathology  of  the  disease  and  on  your  treatment. 

Teeatment, — ^The  prophylactic  treatment  consist  in  the  destruc- 
tion of  the  animal  infected  by  burning  the  bodv  the  moment  the 
disease  is  detected,  this  is  to  prevent  the  disease  from  attacking 
other  animals.  If  3''ou  bury  the  dead  animal,  when  the  soil  is  up- 
turned the  disease  will  break  out  again.  Thoroughly  disirfeot  the 
stable  and  burn  all  sponges,  bags  and  buckets  used  about  the  dis- 
eased horse.  When  the  disease  does  occur  in  man,  the  local  treat- 
ment of  the  ulcer  is  the  most  important.  Treat  it  as  a  malignant 
grow^th.  If  the  ulcer  be  small,  give  an  anaesthetic,  render  the  part 
clean,  make  your  incision  an  inch  from  the  ulcer  and  remove  it 
bodily,  disinfect  the  wound  with  a  bi  chloride  solution  or  chloride 
of  Zinc,  and  if  ycu  think  advisable,  use  the  thermo-cautery ;  if 
you  haven't  the  improved  instrument,  a  red  hot  iron  answers  just 
as  w  ell,  dust  with  iodoform  gauze  and  let  the  ^  ound  heal  by  granu- 
lation. Dress  daily,  and  if  other  ulcers  form,  treat  them  in  the 
same  manner.  If  the  ulcer  is  too  large  for  this  treatment, 
thoroughly  curette  it,  cauterize  it  and  dress  daily.  Combat  the 
constitutional  symptoms  by  administering  strychnine,  whiskey  and 
plenty  of  nutritious,  easily  digested  food. 


PRINCIPLES    OF    SURGERY.  143 

ACriNOMYCOSIS.  —  Aofcinoinycosis  is  a  contagious  clisnase, 
due  to  the  iufectiou  of  the  Ray  futigus  or  Actinomyces.  The  ray 
fundus  is  not,  strictly  speaking,  a  bacteria,  it  does  not  belong  to 
the  group  of  Schizomycetes,  but  is  a  fission  fungi  or  Hyphomy- 
cetes.  It  is  not  microscopic  in  size,  but  is  large  enough  to  be  seen 
with  the  naked  eye.  The  fungus  or  mould  resembles  a  chestnut 
burr,  having  a  depression  in  the  center,  from  which  radiate  fibres 
which  are  tipped  at  the  ends  with  a  bulb.  It  is  found  vtherever 
rank  vegetation  grows,  along  margins  of  streams  where  the  soil  is 
alkaline,  rich  and  moist,  and  from  here  they  are  transmitted  to 
animals  while  grazing  and  from  them  secondarily  to  man.  The 
disease  is  seen  in  herbivora  and  omnivora,  but  never  in  carnivora. 
The  germs  locate  in  the  mouth,  throat  and  stomach  of  animals, 
and  when  located  in  the  mouth  constitutes  a  disease  known  as 
"Lumpy  jaw."  The  germ  is  hard  to  cultivate,  it  onl}^  grows  in 
sterilized  blood  serum  and  doesn't  stain  with  ordinary  aniline  dyes. 
Any  small  portion  of  it  causes  the  disease.  It  is  transmitted  to 
nan  by  eating  the  meat  of  infected  animals. 

Symptoms. — When  the  fungus  is  implanted  in  the  tissues  of  man, 
w^hich  usually  takes  place  in  the  mouth,  throat,  stomach  or  intes- 
tines, it  produces  a  chronic  type  of  inflammation.  It  is  so  chronic 
in  type  that  there  is  no  fever,  redness  or  pain.  Swelling  is  seen, 
which  is  due  to  the  proliferation  of  the  fixed  tissue  cells  of  the 
part,  and  a  tumor  is  formed.  This  tumor  is  usually  diagnosed  as 
a  sarcoma,  but  the  microscope  gives  the  difference.  If  the  tumor 
becomes  infected  with  the  pus  germs  (which  usually  happens)  it 
becomes  congested,  red  and  painful,  the  pus  will  wort  its  way  to  the 
surface,  point  and  discharge.  After  discharging  its  contents,  the 
condition  is  not  improved,  suppuration  continues  and  there  is  a 
constant  oozing  of  pus.  The  patient  becomes  emaciated,  depressed, 
there  is  fever,  night  sweats,  diarrhoea,  etc.  Amyloid  degenera- 
tion of  the  internal  organs  frequently  occurs. 

Diagnosis. — The  diagnosis  is  based  almost  entirely  on  the  micro- 
scope. It  is  much  harder  to  diagnose  after  infection  by  the  pus 
germ,  it  being  taken  for  either  a  tubercular  or  a  syphilitic  abscess, 
but  the  pus  from  actinomycosis  contains  yellow  bodies,  which  can 
be  mashed  between  the  finger,  and  when  examined  under  the  mic- 
roscope shows  the  ray  fungus. 


l-i-l  PRINCIPLES    OF    SURGERY. 

Prognosis. — The  prognosis  is  about  the  sarrie  as  that  for  a  malig- 
nant tumor  as  Carcinoma  or  Sarcoma.  If  the  tumor  is  accessible 
to  surgery,  the  prognosis  is  good,  if  not  the  patient  will  die. 

Treatment. — The  local  treatment  depends  on  the  stage  of  the 
disease.  If  you  can  remov^e  it  before  the  infection  by  the  pus 
germ,  it  will  not  return;  but  if  suppuration  has  taken  place,  and 
the  surrounding  tissues  are  involved,  the  operation  is  much  less 
certain  to  give  relief.  Split  open  the  part  with  a  long,  free  inci- 
sion, gouge  out  the  infected  tissue  with  your  finger  or  curette, 
cauterize  the  surface  with  a  10  per  ceut.  solution  of  chloride  of 
Zinz,  or  the  actual  cautery,  pack  with  gauze  and  dress  daily. 
Usually  there  will  be  a  small  piece  of  infected  tissue  left,  and  the 
disease  will  return,  operate  as  before,  and  repeat  the  operation 
every  time  the  disease  reappears.  Combat  constitutional  symptoms 
with  whiskey,  strychnia  nitrate,  and  good  nutritious,  easily  di- 
gested food. 


LKCTURE  XXXII. 


TUBERCULOSIS. 

TuBEECuLosis  is  a  chronic  inflammation,  caused  by  a  specific  germ 
and  characterized  by  the  formation  of  nodules  or  tubercles.  This 
disease  has  long  occupied  the  attention  of  the  scientific  world.  As 
far  back  as  1826  Laennec  advocated  that  it  was  due  to  a  virus  and 
was  contagious.  Up  to  this  time  the  disease  was  thought  to  be 
hereditar^T-  or  miasmatic.  In  1865  Vellemin  took  up  the  work  of 
Laennec  and  tried  to  demonstrate  it  from  personal  interest,  but 
during  his  investigations  he  was  inoculated  accidentally  and  finally 
died  of  Phthisis;  but  during  his  life  he  demonstrated  conclusively 
that  tuberculosis  could  be  transmitted  by  inoculation.  He  took  a 
lung  from  a  patient  dead  of  tuberculosis  and  injected  one  of  the 
cheesy  masses  into  a  rabbit,  in  six  weeks  the  rabbit  died  of  tubercu- 
lar peritonitis,  he  made  a  solution  from  this  rabbit  and  injected  it 


PRINCIPLES    OF    SURGERY.  145 

into  another,  causing  a  tubercular  abscess.  The  next  investigator 
was  Cohnhein,  in  1877.  He  said  it  was  pretty  theory  to  inoculate 
a  rabbit  and  find  the  tubercles  after  death;  he  wanted  to  watch 
the  process  during  life,  and  he  did  it  in  this  way.  He  made  a 
small  slit  in  the  iris  of  a  rabbit,  implanted  a  siiall  piece  of  tuber- 
cular tissue,  and  watched  its  elfect.  In  one  or  two  days  the  in- 
cision had  healed,  and  the  foreign  mass  could  be  seen  through  the 
transparent  cornea.  Soon  chronic  inflammation  followed  and  in 
two  weeks,  he  could  see  numberiess  miliary  tubercles  in  the  iris. 
In  spite  of  these  researches  nothing  further  ^  as  done  until  1882, 
when  Kobert  Koch,  the  father  of  modern  bacteriology,  published 
a  papei  which  revolutionized  the  field  of  surgery.  lie  had  dis- 
covered the  essential  cause  of  the  disease,  which  is  a  bacillus  which 
bears  his  name,  '"Bacillus  of  Koch."  He  did  mor^  than  discover 
the  germ  of  the  disease,  as  up  to  this  time  the  disease  was  thought 
to  be  confined  to  the  lungs,  but  he  proved  that  it  was  tuberculosis 
and  not  scrofula  which  attacked  bones,  skin,  glands  and  various 
other  tissues  of  the  body.  This  paper  brought  conviction  to  the 
most  skeptical.  In  it  he  laid  now  his  four  laws  in  regard  to  a 
germ  being  the  cause  of  a  disease,  which  ha^e  already  been  enu- 
merated in  a  pre^'ious  lecture.  He  proved  by  these  laws  that  this 
bacillus  was  the  cause  of  tuberculosis;  the  bacilli  was  invariably 
found  in  tte  tubercles,  they  could  be  bred  from  the  tubercles, 
and  would  cause  the  disease  in  a  healthy  animal  when  inoculated 
into  him,  and  when  this  animal  died  the  same  germ  was  found  in 
his  tissues. 

The  term  scrofula  is  a  misnomer,  it  is  a  relic  of  ignorance,  a  bar- 
barious  cloak  to  cover  ignorance  of  the  pathology  of  the  lesion. 
c  was  formerly  used  to  designate  diseases  of  glands,  bone, 
ptSltoneum,  etc.,  bat  the  term  has  been  erased  from  all  modern 
literature.  All  scrofulous  troubles  are  tubercular  troubles,  no  mat- 
ter where  the  disease  is  situated,  in  glands,  bones,  bell}'^  or  joints. 
Out  of  a  hundred  cases  of  so-called  scrofula  examined  by  Koch,  he 
found  the  tubercle  bacillus,  which  he  bred  and  with  them  produced 
tuberculosis  in  other  animals.  When  speaking  of  tuberculosis,  nat- 
urally from  contact  with  the  laity,  you  mean  tuberculosis  of  lung 
tissue,  this  you  should  avoid.  It  is  true  the  lungs  are  more  fre- 
quently the  seat  of  the  disease,  but  it  also  attacks  the  brain,  skin, 
10 


146  PRINCIPLES    OF    SURGERY. 

rectum,  liver,  bladder,  etc.  The  importance  of  this  dread  disease 
can't  be  overestimated.  Fifty  per  cent,  of  all  human  ailments  are 
of  tubercular  origin,  and  it  is  said  that  one-seventh  of  the  world's 
population  die  of  the  disease. 

Inoculating  Experiments. — You  can  take  anj  animal  and  inoc- 
ulate him  with  the  bacillus  of  Koch  and  produce  the  disease.  Some 
animals  are  more  susceptible  to  the  disease  than  others,  the  rabbit, 
hedge  hog,  mouse,  etc. ,  are  more  liable  to  the  disease  than  the 
horse  or  goat.  The  dog  and  cat,  although  so  common,  are  not 
employed,  as  the  disease  in  theni  is  not  so  well  marked.  You  can 
use  foi  inoculating  experiments  the  sputum,  lung  tissue  or  an  emul- 
sion from  tubercular  glands.  You  can  either  triturate  the  material 
in  a  mortar  aod  inject  it  irto  the  animal  or  make  an  aseptic  incision 
in  the  animal  and  plant  a  piece  of  diseased  tissue,  afterwards  sutur- 
ing the  wound.  In  about  ten  days  after  the  inoculation,  the 
symptoms  develop,  fever,  anorexia,  weakness,  exhaustion  and  rapid 
death.  The  fever  is  a  hectic  variety,  which  is  characteristic  of 
tuberculosis,  it  comes  on  in  the  evening  and  abates  in  the  morn- 
ing. After  death,  on  dissecting  the  animal,  you  will  find  tubercles 
all  over  the  organs  and  can  from  this  aninsal's  tissues  reproduce  the 
disease  in  other  animals. 

Inoculating  experiments  on  man,  owing  to  the  laws,  can't  be 
done,  though  sometimes  in  the  future,  laws  will  be  passed  allowing 
the  use  of  criminals  for  this  purpose.  Accidental  inoculations  have 
ODcured,  and  upon  these  we  must  base  our  observations.  A  robust, 
healthy  house  girl,  while  cleaning  the  room  of  a  phthisical  patient, 
accidentally  fell  while  carrying  out  the  spittoon,  and  a  cut  was  in- 
flicted on  her  hand.  In  three  weeks  tubercles  formed,  in  six  weeks 
the  glands  became  involved,  and  in  them  the  characteristic  bacilli 
were  found.  Another  case  is  on  record  where  a  man,  while  m  liv- 
ing, cut  his  knee,  he  went  to  the  branch  and  was  washing  it,  when 
a  friend  passed  by  and  loaned  him  his  handkerchief  to  bind  up  the 
wound.  The  friend  was  tubercular,  the  man  w  as  inoculated  and 
died  of  tuberculosis  in  less  than  a  year.  The  disease  has  been 
transmitted  by  wearing  earrings  of  tubercular  patients.  Lastly,  it 
is  of  historic  record  that  an  old  Jewish  Rabbi  inoculated  twelve 
children  in  following  the  old  Mosaic  laws  of  circumcision.  The 
custom  was  to  stop  the  bleeding  by  the  Rabbi  spitting  wine  on  the 


PRINCIPLES    OF   SURGERY.  147 

bleeding  prepuce,  which  acted  as  a  styptic.  The  old  Eabbi  had 
tuberculosis,  the  children  were  inoculated,  several  died  from  the 
disease,  a  fate  no  less  desirable  than  the  loss  of  the  organ  as  the 
rest  did. 

Causes. — Predisposing. — It  is  "well  known  that  consumption 
runs  in  families.  This  is  not  onl}^  the  idea  with  the  laity,  but  life 
insurance  companies  refuse  all  risks  in  consumptive  families.  How 
can  this  be  accounted  for?  That  the  grandfather,  the  greatuncle, 
the  father,  ihe  father's  brother,  the  aunt  and  the  sister  all  died 
from  tuberculosis.  One  set  of  observers  claim  that  it  is  the  direct 
transplantation  of  the  germ  from  the  mother  or  father  to  the  off- 
spring duiing  conception.  That  a  man  with  tuberculosis  has  the 
germ  in  his  semen;  that  a  woman  with  tuberculosis  has  it  in  her 
ovum.  That  the  germ  may  lay  dormant  during  the  growth  of  the 
child  and  develop  years  afterwards.  They  claim  that  the  bacillus 
from  a  tubercular  woman  can  penetrate  the  placenta,  nature's  filter, 
and  inoculate  the  child.  They  have  reasons  for  this  conviction, 
for  they  have  taken  a  tubercular  mother  and  after  scrupulously 
observing  the  laws  of  asepticity,  delivered  her  of  a  dead  baby, 
immediately  it  was  cut  open  and  it  was  found  to  be  tubercular. 
On  the  other  hand,  their  opponents  have  taken  a  pregnant  guinea 
pig  and  inoculated  her  with  tuberculosis  and  her  offsprings  showed 
no  signs  of  the  disease.  It  does  not  seem  probable  that  the  germ 
can  lay  dormant  for  so  long  a  time  and  then  suddenly  produce  the 
disease.  Other  observers  claim  that  the  germs  cannot  be  trans- 
mitted from  mother  or  father  to  offspring,  but  a  child  from  tuber- 
cular parents  has  a  certain  w^eakness  or  a  hereditary  predisposition 
to  the  disease,  and  if  he  comes  in  contact  with  the  germ  in  after 
years  he  'contracts  the  disease. 

Still  there  are  a  third  set  of  scientists  who  claim  that  the  above 
theories  are  all  bosh.  That  a  man  has  either  got  tuberculosis  or 
he  hasn't  got  it.  The  reason  why  consumption  runs  in  farailiss  is 
because  the  children  have  the  predisposition  to  the  disease  from 
being  born  of  consumptive  parents,  they  are  then  raised  up  with 
the  germs  surrounding  them,  having  consumptive  people  to  live 
with,  eat  with,  sleep  with,  play  with,  they  crawl  on  the  floor,  spat 
on  by  consumptives  and  often  nurse  consumptive  mothers.  If  these 
children  were  not  put  in  such  surroundings,  or  were  isolated  from 


148  PRINCIPLES    OF    SURGERY. 

consumptives  from  the  time  of  birth,  they  would  not  have  tuber- 
culosis. A  case  is  on  record  of  an  old  lady  whose  son  went  West 
and  located  in  a  town  where  there  T\'as  a  Sanitarium  for  tubercular 
patients.  He  contracted  the  disease,  came  home  and  was  nursed 
by  his  mother.  Three  weeks  after  his  death  the  mother  died  of 
tuberculosis,  transmitDed  to  her  predisposed  tissues  by  her  son. 

Essential. — ^The  disease  cannot  develop  without  infection  by  the 
bacillus  of  Koch.  This  is,  with  the  exception  of  the  germ  of  septi- 
cemia in  mice,  the  smallest  pathogenic  germ  known,  in  length  it 
is  only  one-half  the  diameter  of  a  red  blood  corpuscle,  it  has  round 
ends,  slightly  curved  and  may  be  found  singly  or  in  bunches.  It 
multiplies  by  spore  formation,  is  very  hardy,  resisting  heat  and- 
germicides  markedly,  it  is  difficult  to  cultivate,  not  growing  in  any 
of  the  common  media,  but  grows  in  sterilized  blood  serum  and  agar 
asrar  after  the  addition  of  o;lvcerine.  It  is  characterized  bv  not 
staining  with  the  ordinary  dyes;  it  has  to  be  stained  vvith  a  com- 
bination of  dyes,  which  must  be  alkaline  in  reaction.  When 
stained,  unlike  other  germs,  it  cannot  be  bleached  by  either  sul- 
phuric or  nitric  acid.  This  makes  them  easily  recognized.  The 
germ  may  enter  through  the  respiratory,  disgestive,  gen  i  to -urinary 
tract  or  skin.  A  phthisical  patient  will  spit  on  the  floor,  the 
sputum  becomes  dry  and  is  scattered  over  the  room  and  is  taken 
into  the  lungs;  if  the  lungs  are  healthy  there  is  no  danger,  but  if 
there  is  bronchitis  or  the  lung  tissue  is  in  a  lowered  state  of  vi'ality 
the  disease  will  be  contracted.  Milk  from  a  tubercular  cow  or 
meat  from  a  tubercular  animal  may  cause  the  disease,  and  it  is  only 
because  of  the  acidity  of  the  stomach  that  we  are  protected,  but 
people  with  a  bad  digestion  or  those  who  have  been  taking  bicar- 
bonate of  soda,  thus  rendering  the  secretions  of  the  stomach  at  the 
time  alkaline,  are  extrenaely  liable  to  contract  the  disease  frcm 
tubercular  meat  or  milk.  The  disease  may  be  contracted  b\^  hav- 
ins:  connection  with  a  tubercualr  woman.  The  unbroken  skin  acts 
as  a  barrier  against  infection,  but  surgeons  and  butchers  in  their 
daily  work  are  often  inoculated  by  cuttino;  themselves. 


PRINCIPLES    OF    SURGERY.  149 


TUBERCULOSIS— Continued. 

Tubercle. — A.  tubercle  is  as  much  the  specific  lesion  of  tubercu- 
losis as  a  chancre  is  of  syphilis.  It  is  the  result  of  chroiiic  iaflam- 
mation.  It  is  a  small  grayish  nodule,  due  to  an  aggregation  of 
cells  and  characterized  by  the  fact  that  it  contains  no  blood  vessels. 

PI iSTO LOGICAL  Structure. — A  tubercle  is  composed  of  epithelioid 
cells,  giant  cells,  leucocytes,  bacilli  and  a  reticulum.  The  epithe- 
lioid cells  are  round  or  oval,  twice  as  large  as  a  \^hite  blood  cor- 
puscle, composed  of  fine  granular  protoplasm,  with  two  or  three 
nuclei.  They  are  in  large  numbers,  making  up  ths  major  portion 
of  the  tubercle,  Theii^  origin  is  a  disputed  question.  They  are 
the  result  of  the  proliferation  of  the  fixed  cells  of  the  part,  the 
chronic  inflammation  stimulates  them  to  proliferating  and  these 
cells  are  formed.  The  giant  cells  are  a  hundred  times  as  large  as 
a  white  corpuscle,  made  up  of  fine  granular  protoplasm,  with  from 
fifteen  to  twenty  nuclei,  which  are  jiot  arranged  in  the  center,  but 
around  the  periphery  of  the  cell  in  the  shape  of  a  crescent  or  half 
moon.  Their  origin  is  also  a  disputed  question,  but  they  are 
nothing  but  overgrown  epithelioid  or  eixbryonal  cells,  which  have 
sprung  from  the  fixed  tissue  cells,  but  instead  of  multiplying  and 
dividing  it  apropriates  its  nutriment  towards  its  own  growth.  The 
leucocytes  are  the  ordinary  white  blood  corpuscles;  their  origin  is 
from  the  neighboring  blood  vessels,  the  chronic  inflammation  hav- 
ing caused  increased  porosity  of  the  blood  vessels,  rheir  escape  is 
made  easy.  The  bacilli  of  Koch  is  also  found  in  the  tubercle,  a 
description  of  which  is  given  in  the  preceding  lecture.  The 
tubercle  is  held  together  by  a  delicate  framework  of  connective 
tissue.  This  is  not  a  newly  formed  tissue,  but  is  the  old  connective 
tissue  of  the  part,  simply  pushed  apart  by  the  growth  of  the  cells. 
The  arrangement  of  the  above  elements  in  a  tubercle  is  into  three 
strata.  When  examined  under  the  microscope  the  following  ar- 
rangement will  be  noticed  from  the  center  outw  ard.      We  first  have 


150  PRINCIPLES    OF    SURGERY. 

in  the  center  the  giant  cells,  two  or  three  in  number,  around  these 
are  the  epithelioia  cells  and  next  comes  the  layer  of  leucocytes;  bind- 
ing this  mass  together  is  seen  the  reticulum  and  scattered  through- 
out the  tubercle  will  be  seen  the  bacilli,  which  are  usually  more 
numerous  in  the  middle  layer  or  epithelioid  cells  and  some  may  be 
seen  perforating  the  giant  cells.  The  tubercle  contains  no  blood 
vessels  and  therefore  has  to  obtain  its  nutrition  by  absorption  and 
percolation. 

Development. — ^Essential  for  the  development  of  a  tubercle  is 
the  implantation  of  thd  bacilli  of  Koch  in  the  tissues.  "When  im- 
planted they  multiply  and  produce  their  characteristic  toxins,  w^hich 
acting  on  the  tissues,  sets  up  a  chronic  low  grade  of  inflammation. 
This  inflammation  causes  the  vessels  in  the  neighborhood  to  be- 
come more  porons  and  leucocytes  escape  and  wander  to  the  infected 
point.  The  fixed  cells  are  now  stimulated  to  proliferate,  and 
epithelioid  cells  are  formed  containing  one  or  two  nuclei,  they 
form  slowly  at  first,  but  soon  the  process  rapidly  increases  and  a 
considerable  bulb  of  them  are  formed.  Some  of  these  cells  will 
not  divide  and  multiply  like  the  rest,  but  grows  very  large  and 
forms  giant  cells  with  from  fifteen  to  twenty  nuclei.  The  connec- 
tive tissue  is  being  pushed  asunder  as  the  cells  are  formed,  and  thus 
the  reticulum  is  formea.  'Now  we  have  a  tubercle  with  bacilli 
studded  all  through  it.  It  is  at  first  microscopic  in  size,  but  soon 
becomes  as  large  as  a  , millet  seed,  when  it  can  be  seen  with  the 
naked  eye,  and  appears  grayish.  Other  tubercles  now  form,  in- 
crease in  size  and  two  or  three  may  coalesce.  Gradually  the  whole 
of  the  surrounding  tissue  is  attacked  and  becomes  a  solid  tubercu- 
lar mass. 

Caseous  Degenekation. — The  tubercle,  being  poorly  nourished, 
dies,  the  centre  first,  this  point  being  the  longest  deprived  of  nu- 
trition, also  the  longest  exposed  to  the  action  of  the  bacilli  and 
their  toxins.  We  have  coagulating  necrosis,  the  mass  becomes  a 
yellow,  cheesy  looking  substance  and  hence  the  name  caseous  de- 
generation. Owang  to  the  fact  that  some  of  the  tubercles  are  yel- 
low and  others  grayish,  we  speak  of  gray  or  miliary  tubercles  and 
yellow  or  caseous  tubercles. 

Symptoms. — When  you  remember  that  tuberculosis  may  attack 
almost  any  portion  of  the  body,  you  can  readily  see  that,  although 


PRINCIPLES    OF    SURGERY.  151 

the  local  syraptoins  in  each  locality  resemble  each  other,  still  there 
is  a  difference,  and  for  this  reason  the  local  symptoms  will  be  given 
under  each  respective  head.  The  general  syraptoins  due  lo  the 
absorption  into  the  system,  the  toxins  of  the  specific  germ  are  as 
folloMs:  Hectic  fever,  which  is  pathognomonic  of  tuberculosis,  is 
always  present.  There  is  exhiliration  when  it  is  at  its  height  and 
profound  depression  when  absent.  It  is  highest  in  the  evening  and 
falls  by  morning.  There  is  a  gradual  failing  of  strength,  emacia- 
tion, anorexia,  night  sweats,  prostration,  diarrhoea,  collapse  and 
dearh. 

Diagnosis. — The  diagnosis  is  based  on  the  history.  If  you  be- 
lieve in  heredity,  search  his  family  history,  see  if  he  tvas  born  of 
tubercular  parents  and  raised  in  tubercular  society.  Secondly,  the 
diagnosis  is  based  on  the  symptoms,  not  so  much  on  the  local  as 
the  general  symptoms,  such  as  hectic  fever,  emaciation,  etc.  When 
the  diagnosis  is  doubtful  an  infalliole  test  is  the  microscope  or  in- 
oculation. Send  some  of  the  sputum  if  the  disease  is  situated  in 
the  lungs,  clip  off  a  piece  of  the  skin,  if  it  is  situated  on  the  skin, 
or  if  it  is  in  a  bone  send  some  of  the  exuded  tubercular  material  to 
a  microscopist  for  examination.  Send  it  in  a  well  corked  bottle  of 
either  alcohol  or  chloral  hydrate.  Inoculation  is  a  still  more  re- 
liable test,  and  can  be  done  where  you  haven't  the  facilities  for 
microscopic  examination.  Introduce  some  of  the  suspected  mate- 
rial into  a  guinea  pig  or  rabbit,  kill  it  in  ten  days,  and  if  the  patient 
is  suffering  from  tuberculosis,  the  animal  will  show  the  character- 
istic tubercles.  This  is  really  a  more  reliable  test  than  the  micro- 
scope, and  the  only  differential  test  to  tell  a  tubercular-nodule  from 
a  syphilitic  nodule. 

Prognosis. — The  prognosis  is  based  on  the  age,  general  health, 
extent  to  which  the  disease  has  progresstd  and  to  its  accessibility 
to  surgical  interferences;  thus  the  prognosis  is  better  in  a  young, 
robust  man  than  in  an  old  man,  without  vitality  and  with  a  poor 
digestion:  it  is  also  better  if  it  occupies  only  a  small  area  and  is 
situated  on  the  skin,  where  it  can  be  radically  removed  than  if 
located  in  the  liver  or  lung. 

Treatment, — The  local  treatment  consist  in  the  radical  and  com- 
plete removal  of  the  infected  tissue.  If  this  is  possible  do  so 
promptly,  but  if  you  can't  completely  remove  it,  never  adopt  half 


152  PRIXCIPLES    OF    SURGERY, 

v.ay  measures,  let  it  alone.  If  you  can  radically  remove  it,  you 
only  have  to  wait  for  recoYery,  but  if  you  only  partially  remoYe 
it,  you  do  harm  ly  deYitilizing  the  tissues  whicli  nature  is  using  as 
a  defence.  In  the  general  treatment,  diet  is  of  the  first  impor- 
tance. Give  good,  nutritious  food,  as  beef,  mutton,  chicken,  pota- 
toes, milk  and  eggs.  Give  as  a  stimulant  good  old  rye  whiskey, 
administered  in  ccld  water  before  meals;  beer  and  sherry  is  also 
good.  They  should  be  clad  in  good,  warm  llannels,  in  order  to  be 
able  to  take  exercise,  no  matter  ^hat  the  state  of  the  weather  be. 
Climate  markedly  influences  the  progress  of  the  disease,  a  high 
country,  with  dry  atmosphere,  such  as  at  Thomasville,  Ga,,  is  the 
best.  Cold  baths  should  be  taken  regularly,  they  tone  up  the  sys- 
tem and  assist  him  in  standing  cold  weather.  Tonics  of  various 
kinds  should  be  given,  as  gentain.  iron  and  nrx  Yomica.  Altera- 
tives should  be  given,  of  which  Guaiacol  and  Cod  Liver  oil  rank 
first.  Cod  Liver  is  not  only  a  good  alterative,  but  is  also  a 
splendid  food.  Xever  use  emulsions,  they  are  a  delusion  and  a 
snare,  only  containing  about  10  per  cent,  of  Cod  Liver  oil.  Give 
pure  Norwegian  oil.  half  an  hour  after  meals;  in  this  time  the  food 
will  haYe  been  digested  and  passed  into  the  small  intestines.  Com- 
mence with  a  teaspoooful  and  steadily  increase  the  dose  to  a  cable- 
spoonful.  If  the  stomach  refuses  it,  ^ait  a  week  or  so  and  com- 
mence it  acrain.  I  do  not  believe  the  good  effect  of  Cod  Liver  oil 
is  so  much  from  the  alterative  effect  of  the  Iodine  it  contains,  but 
it  acts  well  on  account  of  the  fat  it  contains;  pure  cream  is  almost 
as  good,  administered  in  quantities  from  a  half  to  a  C]uart  daily. 
Koch's  tuberculin  has  almost  lost  its  interest  to  the  profession,  but 
about  five  years  ago  it  caused  c^uite  a  stir  among  as.  It  is  a  yel- 
low fluid,  of  alkaline  reaction,  made  from  the  bacilli  gro^vn  in 
gh^cerine  and  the  germ  is  afterwards  killed  by  heat.  One  drop  of 
it  produces  marked  effect,  causing  fever  and  inflammation,  but  its 
curative  powers  are  "mZ."  Its  discovery  has  led  to  investigation, 
which  will  no  doubt  soon  pan  out  a  cure. 


PRINCIPLES   OF   vSt:kgep>y.  153 


LKCTURE  XXXI^^. 


CLINICAL  FORMS  OF    SUEGICAL    TUBERCULOSIS. 

Tuberculous,  Cold,  Chronic,  Wandering  and  Migratory  Ab- 
scess are  synonymous  terms  used  to  designate  a  collection  of  tuber- 
cular matter  in  tissues.  The  term  abscess,  as  tiere  used,  does  not 
accord  vvith  the  definition  Ol  the  term  previously  given,  as  they 
do  not  contain  pus,  but  it  is  retained  because  it  was  used  before  the 
distinction  and  cause  was  discovered.      It  is  a  misnomer. 

Cause. — Tubercular  abscesses  are  always  secondary  manifesta- 
tions of  some  tubercular  lesion  of  long  standing.  They  never  occur 
primarily.  They  are  frequen<-ly  seen  following  tuberculosis  of  the 
spine  (Pott's  disease),  hip  joint  disease  (coxalgia)  and  glands. 
Therefore  to  cure  them,  your  treatment  must  be  directed  to  the 
primary  focus. 

Pathology.— We  first  have  infection  by  the  bacillus  of  Koch,  it 
lodges  in  some  portion  of  the  ecomomy,  grows  and  multiplies  and 
sets  up  a  chronic  inflammation,  with  the  formation  of  small  miliary 
tubercles.  These  tubercles  increase  in  size  and  number,  and  the 
infected  area  is  transfered  into  a  granular  tubercular  mass.  As 
these  tubercles  contain  no  blood  vessels  and  are  therefore  im- 
properly nourished,  they  undergo  coagulating  necrosis,  followed  by 
caseation  and  liquifaction,  and  you  have  a  fluid  closely  resembling 
pus,  but  it  is  not  pus,  because  it  does  not  contain  pus  cocci  or  pus 
cells.  It  is  a  white  fluid,  containing  small  lumps  of  dead  tissue  and 
sometimes  bone  crumbs.  This  material  is  held  in  positioQ  and 
prevented  from,  being  diffused  into  the  adjacent  tissue  by  a  wall, 
which  ig  nothing  but  the  consolidaticn  of  granulation  tissue  which 
forms  beyond  the  infected  area.  When  incised,  it  will  be  found  to 
be  a  thick,  soft,  bluish  membrane,  very  vascular  and  thoroughly 
infected  and  should  therefore  be  removed.  As  the  abscess  gets 
larger,  the  membrane  stretches  and  grows;  soon  it  begins  to  mi- 
grate, begins  to  w^ander  through  the  tissues,  which  is  accomplished 
by  the   physical  law  of  gravity.      If  it  commences  on  the  neck,  it 


154  PRINCIPLES    OF    SURGERY. 

will  travel  down  and  point  somewiiere  near  the  clavicie;  if  it  com- 
mences in  the  back,  it  may  travel  and  point  in  the  groin.  They 
point  ana  break  far  distant  from  the  primary  focus. 

Symptoms. — The  cold  abscess  has  some  of  the  synptoms  of  a  hot 
abscess,  but  lacks  others.  In  an  ordinary  or  hot  abscess  there  is 
pain,  heat,  redness,  swelling  and  fluctuation.  The  tubercular  ab- 
scess gives  no  pain,  redness  or  heat;  the  only  symptoms  it  has  of 
an  ordinary  abscess  is  swelling  and  fluctuation.  The  first  symp- 
tom which  attracts  j^our  attention  is  swelling,  on  palpation  you 
get  fluctuation,  the  swelling  wanders,  it  was  first  high  up  in  the 
back,  and  now  threatens  to  burst  in  the  groin.  If  the  swelling  is 
not  attended  to,  it  will  become  a  dusky  color,  from  pressure  the 
skin  becomes  thin  and  finally  ruptures  and  the  tubercular  material 
escapes.  If  the  abscess  points  in  the  lumbar  region,  it  is  called  a 
Lumbar  abscess;  if  it  points  along  the  course  of  the  psoas  muscle 
it  is  called  a  Psoas  abscess,  and  if  it  points  in  the  iliac  region  it  is 
called  a  Iliac  abscess;  but  remember  that  the  name  of  the  region 
in  which  the  abscess  is  located  gives  no  indication  where  the  prim- 
ary focus  is. 

Diagnosis, — The  diagnosis  is  based  on  the  history,  as  if  a  man 
with  Pott's  disease,  who  has  a  fluctuating  swelling  on  his  back,  or 
with  hip  disease,  showing  a  swelling  near  the  knee,  upon  the  en- 
largement and  fluctuation  coming  on  slowly,  accompanied  by 
neither  pain,  heat  nor  redness.  If  the  history  and  symptoms  are 
not  confirmatory,  aspirate,  dra\s  out  the  fluid  and  examine  it  for 
the  bacillus  of  Koch. 

Prognosis. — A  young,  healthy  adult  has  a  greater  chance  of  re- 
covery than  and  old,  enfeebled  person.  A  small  abscess  gives  bet- 
ter hopes  than  a  large  one.  And  it  is  more  favorable  if  located 
where  it  is  amenable  to  the  surgeon's  knife. 

Treatment. — The  treatment  depends  on  the  fact  whether  or  not 
the  primary  focus  can  be  radically  removed.  If  it  is  in  the  glands 
of  the  neck,  it  can  be  removed,  but  if  it  is  a  vertebrtS  that  is  dis- 
eased, other  means  will  have  to  be  adopted  which  are  more  pallia- 
tive. 

The  radical  treatment  consist  of  making  a  free  incision,  curetting 
the  walls,  following  the  various  ramifications  and  removing  all  the 
infected  tissue.     If  you  can  do  this  the  wound  will  heal  by  primary 


PRINCIPLES    OF    SURGERY.  155 

inteation.  "Where  this  cannot  be  done,  as  when  a  vertebriB  is  in- 
volved, you  must  practice  aspiration,  irrigation  and  iodoformiza- 
tion.  If  you  simply  incise  one  of  these  abscesses,  you  condemn 
your  patient  to  death,  for  no  matter  how  carefully  it  is  dressed, 
sooner  or  later  it  will  become  infected  from  without  by  the  pus 
germ.  Practice  this  method,  which  was  devised  about  ten  years 
ago  and  has  saved  many  lives.  Render  the  skin  clean,  take  an 
aseptic  trocar  and  with  clean  hands  plunge  it  into  the  abscess,  draw 
the  skin  to  one  side  and  plunge  it  in  obliquely,  thus  forming  a 
valve  to  prevent  the  escape  of  fluid  when  the  trocar  is  withdra^^  n; 
withdraw  the  blade  of  the  trocar  and  let  the  material  escape  through 
the  canula.  Tf  the  canula  becomes  plugged  by  the  cheesy  masses, 
pull  them  out  with  an  aseptic  wire  prepared  for  the  purpose. 
After  the  fluid  has  escaped,  irrigate  the  cavity  through  the  canula 
with  a  Tincture  Iodine  solution,  throw  it  into  the  abscess  repeatedly 
until  it  comes  back  untainted  by  the  tubercular  material;  now  dis- 
solve in  glycerine,  olive  oil  or  Ether  enough  iodoform  to  make  a 
10  per  cent,  solution  (10  parts  to  100  parts  glycerine);  as  iodoform 
is  poisonous,  only  inject  the  first  tirce  one  drachm  of  the  solution, 
and  if  this  is  well  borne  increase  the  amount.  "Withdraw  the 
canula  and  the  valve  formed  by  the  skin  prevents  the  iodoform 
from  escaping.  Manipulate  the  part  and  so  difl'use  the  iodoform 
into  all  parts  of  the  cavity.  Repeat  the  operation  every  ten  days, 
increasing  the  amount  of  iodoform  solution  each  time  until  the 
abcess  disappears.  While  treating  the  abscess,  build  up  the 
patient's  general  health  with  good  diet,  tonics,  stimulants  and 
plenty  of  outdoor  exercise. 

TrBERcuLosis  OF  THE  Iris. — TMs  trouble  is  not  uncommon,  but 
is  rarely  seen  in  general  practice,  bsing  of  such  a  nature  as  to  be- 
long to  the  opthalmologist. 

Cause.-— When  the  disease  occurs,  it  is  caused  hj  direct  inocu- 
lation, as  a  piece  of  infected  filing  penetrating  the  iris,  by  an 
operation  performed  by  a  dirty  surgeon,  or  the  germ  may  be  float- 
ing in  the  blood  and  lodges  in  the  iris. 

Symptoms. — The  symptoms  are  easily  discernable.  The  nodules 
can  be  seen  growing  through  the  transparent  cornea. 

Diagnosis  is  made  by  the  character  and  symptoms  of  the  disease. 

Teeatmen^t. — To  do  an  iredectomy  would  be  absurd;  the  whole 


156  PRINCIPLES    OF    SURGERY. 

eye  must  be  removed.  Before  performing  the  operatioD,  examine 
the  other  eye  and  if  it  is  diseased  or  he  has  tuberculosis  in  other 
portions  of  the  body  let  him  alone. 

TuBEKcuLosis  OF  THE  IxTEENAL  Eae. — This  trouble  is  rare,  though 
it  sometimes  occurs.  The  germ  finds  a  lesion  in  the  tympanum  or 
semi-circular  canals,  locates  and  produces  their  baneful  effect. 

Symptoms.  —  Sometimes  there  is  a  discharge  of  tubercular  ma- 
terial, but  this  is  not  constant;   there  is  pain  and  deafness 

Diagnosis. — The  diagnosis  can  only  be  made  by  the  microscopic 
examination  of  the  <lischarge 

Treatment. — Clean  the  ear  thoroughly,  split  it  open  from  be- 
hind, scoop  out  the  diseased  tissue  and  disinfect.  In  performing 
this  operation  thereisdanger  of  puncturing  the  mastoid  cells,  caus- 
ing tuberculosis  of  the  meninges  and  death. 

Tuberculosis  ot  the  Nose  and  Throat. — This  disease  is  common. 
It  can  be  seen  in  any  patient  \vith  phthisis  pulmonalis  if  they  have 
had  the  disease  any  length  of  time.  The  mucous  membrane  of  the 
nose  and  throat  becomes  studded  with  tubercles. 

Treatment. — The  treatment  is  paliative,  no  radical  cure  being 
possible.  Cauterize  the  nodules  and  dnst  with  some  antiseptic 
pc  w  der. 

Tuberculosis  of  the  Mouth  and  Tongue. — This  disease  is  fairly 
common,  and  may  occur  by  primary  infection  from  eating  infected 
food.  After  localizing,  the  germs  rapidly  multiplies,  forming  ulcers 
upon  the  tongue,  tonsils,  hard  or  soft  palate.  They  are  usually 
flat  and  oval,  coverod  with  a  soft  white  membrane,  which,  when 
brushed  off,  bleeds  freely.  It  may  be  mistaken  for  syphilis  or 
cancer. 

Diagnosis. — The  differential  diagnosis  from  syphilis  and  cancer 
is  difficult,  but  can  be  made  by  the  use  of  the  microscope  by  find- 
ing the  bacillus  of  Koch.  They  can  be  told  from  epithelioma  by 
the  fact  that  epithelioma  commences  superficially  and  penetrates 
deeply;  tuberculosis  commences  deep  and  comes  to  the  surface; 
and  in  in  epithelioma  the  neighboring  glands  soon  becomes  in- 
volved, while  in  tuberculosis  it  takes  a  long  time.  It  can  be  told 
from  syphilis  by  administering  Iodide  Potasb,  and  if  it  is  syphilis 
there  will  be  marked  incproveraent,  but  will  have  no  effect  if  it  is 
tubercular. 


PRINCIPLES    OF    SURGERY.  157 

Treatment. — The  treatment  coasist  in  as  radical  removernent  as 
the  part  allows.  It  is  situated  on  the  tongue,  remove  the  organ 
with  a  clean  cut  far  from  the  ulcer.  If  the  ulcer  is  on  the  hard 
or  soft  palate,  cauterize  it  with  the  blunt  knife  of  the  thermo-cau- 
tery.      Give  detergents,  mouth  \^; ashes  and  stimulants. 


LECTURE  XXXV. 


CLINICAL   FORMS    OF   SURGICAL   TUBERCULOSIS.— 

CoNTmUED. 

TuBEEcuLosis  OF  THE  Intestines. — This  is  a  fairly  common 
trouble,  and  may  occur  eithsr  by  primary  or  secondary  infection. 
It  is  due  to  the  implantation  of  the  germ  of  Koch  upon  the  mucous 
membrane  of  the  intestines.  If  occurring  primarily,  the  germ  is 
introduced  by  the  food  or  drink,  milk  being  a  common  source  of 
infection,  especially  in  children;  and  if  occurring  secondarilv,  it  is 
by  extension  of  the  disease  from  some  other  tubercular  foci. 

Symptoms. — The  symptoms  are  vague  and  illy  defined.  There 
is  a  feeling  ol:  weigbt  in  the  abdomen,  vague  pains,  general  feeling 
of  malaise,  loss  of  appetite,  strength  and  flesh.  There  is  alterna- 
ting diarrhoea  and  constipation,  hectic  flush,  rapid  pulse,  sweating 
and  prostration. 

Treatment.— This  disease  properly  belongs  to  the  domains  of 
medicine,  and  this  accounts  for  the  number  of  deaths  from  the 
disease.  When  the  surgeon  is  called  in,  the  bowels  have  generally 
become  occluded  and  a  laparotomy  has  to  be  performed.  After 
opening  the  belly  find  the  tubercular  area,  which  is  usually  near 
the  ileo-caecal  valve,  and  resect  it.  Many  patients  have  been 
treated  in  this  manner  and  recovered.  In  performing  this  opera- 
tion observe  the  usual  aseptic  precautions,  make  your  incision,  draw 
out  the  gut,  remove  the  diseased  part  and  then  either  suture  the 
ends  together  with  catgut  or  use  a  Murphy  button.  Intestinal 
surgery  has  made  rapid  strides  in  late  years.  I  have  resected  as 
much  as  sixteen  inches  of  the  gut  with  recovery,  using  the  Mur- 


158  PRINCIPLES    OF   SURGERY. 

phy  button  in  the  operation.  Theorists  claim  that  the  Murphy 
button  has  seen  its  day  and  recommend  the  old  method  of  suturing, 
but  not  so;  it  is  true  that  the  Murphy  "button  is  not  without  dis- 
advantages, but  scientists  will  soon  give  us  a  perfect  device  and  it 
will  be  on  the  order  of  the  Murphy  button.  It  is  certainly  the 
best  device  yet  invented. 

TiBEEcuLosis  OF  THE  Rectum. — This  troublc  is  very  common. 
Three  per  cent,  of  people  suffering  from  tuberculosis  of  the  lungs 
have  a  tubercular  fistula.  It  is  always  secondary,  and  due  to  ex- 
tension from  some  pre-existing  focus.  In  a  previous  lecture,  you 
were  advised  to  operate  on  these  cases,  simply  to  give  relief.  A 
tubercular  woman  came  to  me  some  time  siEce  suffering  severe 
pain  on  defecation,  was  run  dotvn  in  health  and  very  much  emaci- 
ated. On  examination  I  found  the  rectum  studded  with  tubercles 
and  also  a  tubercular  stricture.  I  dilated  the  rectum  with  bougies 
and  my  thumbs,  removed  the  tubercles  with  a  spoon,  irrigated  the 
rectum  with  an  Iodine  solution  and  removed  her  from  the  operating 
table.  I  then  washed  out  the  rectum  the  next  day  with  water,  and 
then  an  iodine  solution  and  inserted  a  suppository  containing  30 
grains  of  iodoform,  this  was  repeated  for  a  while,  and  when  I  last 
saw  her,  the  improvement  'was  renaarkable. 

TuBEKcuLosis  OF  Tendon  Sheaths, — Tuberculosis  sometimes  at- 
tacks tendon  sheaths,  especially  of  the  tendons  at  the  wrist  joint, 
constituting  a  disease  known  as  Tubercular  tendo-synovitis.  It 
vpas  long  thought  to  be  only  of  secondary  infection,  due  to  exten- 
sion from  some  tubercular  joint,  but  lately  it  has  been  proven  to  be 
also  of  primary  infection  (brought  by  the  blood),  and  extending  to 
joints  or  other  parts  unless  checked. 

Symptoms. — The  symptoms  are  plam.  There  is  a  slow  forming- 
swelling  along  the  tendons  line,  which  is  painlesiii  and  fluctuates. 
It  ususally  commences  in  the  flexor  tendons  in  the  palm  of  the 
hand,  extending  beneath  the  annular  ligament  to  the  middle  of  the 
forearm.  There  is  a  specific  formation  of  granular  tissue  within 
the  tendon  sheath,  the  sheath  is  separated  from  the  tendon  by  a 
yellow  fluid,  which  contains  the  characteristic  rice  Dodies.  Tbese 
bodies  are  coagulated  fibrin  and  are  very  infective. 

Tkp:atment. — If  the  disease  is  left  alone,  death  invariably  occurs 
from  involvment  of  other  tissues.      Operative  measures  should  be 


PRINCIPLES    OF    SURGERY.  159 

prompt  and  thorough.  Render  the  part  bloodless  with  Esraarch's 
bandage  and  apply  a  tourniquet,  make  the  skin  clean,  as  the  wound 
must  heal  by  primary  intention.  Make  a  long  sweeping  incision, 
exposing  the  whole  of  the  tendon,  allow  the  fluid  to  escape,  irrigate 
(vith  a  Tinct.  Iodine  solution,  and  then  with  a  sharp  spoon,  curette 
out  all  the  infected  tissue,  clipping  all  resisting  tissue  with  scissors, 
scrape  the  tendon  until  you  come  to  healthy  tissue  and  if  necessary 
resect  it.  If  the  tendon  is  situated  deeply,  don't  hesitate  to  sever 
the  tendons  in  your  way,  and  the  same  must  be  done  if  the  annu- 
lar ligament  keeps  you  from  doing  thorough  work.  After  com- 
pleting your  work,  suture  the  tendons  and  annular  ligament,  unite 
the  wound  with  catgut,  put  the  arm  on  a  splint  to  prevent  con- 
traction and  dress  with  plenty  of  cotton.  Don't  remove  the  dress- 
ing for  two  weeks,  when,  if  your  work  was  thorough,  the  wound 
will  be  healed.  If  the  joint  be  stiff  after  removing  the  splint,  use 
massage. 

Tuberculosis  of  the  Pekitoneum. — This  disease  is  of  frequent 
occurrence.  It  is  more  common  in  women  than  in  men.  It  is 
amenable  to  surgery  and  brilliant  results  follow.  It  may  be  pri- 
mary or  secondary;  if  the  former,  the  gem  is  brought  by  the  blood; 
if  the  latter  (which  is  more  usual),  by  extension  from  some  other 
tubercular  foci,  as  from  the  intestines,  liver  or  fallopian  tubes. 
The  disease  may  be  followed  by  two  results,  either  ascites  or  watery 
accumulation  in  the  cavity  or  by  plastic  or  solid  accumulation. 
When  ascites  results  one  or  two  things  occur,  the  fluid  either  re- 
mains free  in  the  cavity,  or  it  may  become  connned  by  adhesions 
or  an  artificial  wall  fop  it  is  formed.  When  it  is  free,  it  resembles 
cirrhosis  of  the  liver.  When  the  patient  la^'s  on  his  back  you  get 
a  dull  sound  on  percussion,  this  is  because  all  the  fluid  has  by 
gravity  gone  backtvard  and  the  guts  protrude.  When  the  fluid  is 
circumscribed  by  adhesions,  the  viscera  and  omentum  become  stuck 
together  and  the  symptoms  resemble  those  of  an  ovarian  tumor. 
When  the  disease  results  in  a  plastic  or  solid  accumulation,  you  will 
find  on  cutting  into  the  abdomen  that  the  viscera  are  all  glued  to- 
gether by  a  plastic  gelatinous  mass.  The  ascitif^.  variety  is  curable, 
the  plastic  variety  is  not.  We  will  therefore  only  discuss  the  cu- 
rable variety. 

Diagnosis. — It  can  only  be  told  from  dropsy  when  the  fluid  is 
free  by  a  careful  examination  of  each  organ,  by  the  history  and  by 


160  PRINCIPLES    OF    SURGERY. 

introducing  the  trocar,  obtaining  some  of  the  fluid  and  examining 
it  under  the  microscope.  It  is  impossible  to  tell  the  circumscribed 
Tariety  from  an  ovarian  tumor,  as  it  usually  occurs  in  'v^omen, 
grows  slowly  aud  fluctuates  od  deep  pressure;  however,  both  con- 
ditions demand  operative  methods,  and  you  can  tell  the  difference 
after  entering  the  belh^.  The  amount  of  fluid  varies  from  one  or 
two  pints  to  eight  or  ten  gallons,  it  is  amber  colored  and  contains 
rice  bodies. 

Tkeatment. — Open  the  bell}^  and  let  the  fluid  escape,  when  it  is 
localized  by  adhesions  break  them  down.  Examine  the  ovaries, 
fallopian  tubes,  appendix,  glands  and  omentum,  and  if  any  of  them 
are  diseased,  remove  them.  Irrigate  the  cavity  with  gallons  of  hot 
water,  dust  with  iodoform  in  unmeasured  quantities,  put  in  a  large 
glass  drainage  tube,  which  should  extend  to  the  bottom  of  the 
cavity  or  "cul  de  sac"  in  front  of  the  rectum,  suture  the  wound 
and  instruct  the  nurse  to  empty  the  cavity  daily;  the  first  day  there 
may  be  as  much  as  a  pint  of  fluid,  but  it  gradually  disappears, 
when  you  can  remove  the  drainage  tube. 

TUBEECULOSIS  OF  THE  SkIIn',    LuPUS,    LuPUS-YuLGAKIS  OK   ScROFULO- 

DEEMA  are  s3"nonymous  terms  used  to  designate  a  disease  of  the 
skin  caused  by  the  tubercle  of  Koch.  The  disease  is  not  so  com- 
mon as  might  be  expected  from  the  large  area  exposed. 

Pathological  Anatomy. — The  disease  is  most  often  seen  on  the 
face  and  hands,  the  germ  being  inoculated  through  a  crack  or 
ahrasioQ.  The  bacilli  locates,  produces  their  toxins  which  causes 
a  chronic  inflammation,  tubercles  form  and  approach  the  surface, 
finally  from  pressure  the  skin  dinintegrates  and  leaves  a  ravs  sur- 
face exposed.  Soon  the  wound  becomes  infected  hy  the  pus  germ 
and  a  large  ulcer  forms  as  a  result  of  double  infection.  If  it  is  on 
the  face,  other  tissues  become  involved,  and  the  ctieeks  and  nose 
may  be  eaten  away. 

Diagnosis. — The  disease  is  often  difficult  to  differentiate  from 
cancer  and  syphilis.  First  try  and  obtain  the  history  of  the  case. 
If  the  family  is  tubercular,  make  a  microscopic  examination  of 
some  product  of  the  disease  for  the  bacillus  of  Koch  or  inoculate  a 
guinea  pig  and  watch  the  results.  It  can  be  told  from  syphilis  by 
the  use  of  Iodide  Potash,  which  markedly  influences  syphilis,  but 
has  no  effect  on  tuberculosis.  The  microscope  will  differentiate  it 
from  cancer. 


PRINCIPLES    OF    SURGERY.  161 

Peognosis. — The  prognosis  is  unfavorable.  The  patient  usually 
dies  of  Phthisis  puhnonalis. 

Treatment. — Arsenic  in  three  minim  doses  seems  to  do  good, 
administer  tonics,  stimulants  and  good  food.  The  local  treatment 
consist  in  the  radical  removal  of  the  diseased  tissue.  If  it  is 
possible  use  the  knife,  cut  through  healthy  tissue  and  remove  the 
diseased  tissue  bodily,  then  assist  healing  by  skin  grafting.  If 
this  is  not  advisable,  curette  out  all  the  infected  tissue,  dust  with 
iodoform  and  dress  antiseptically.  As  fast  as  the  nodules  reappear 
attack  them  with  the  curette  or  thermo-cautery.  Koch's  tuber- 
culin is  said  to  do  good  in  this  form  of  the  disease. 


LECTURK  XXXVI. 


CLINICAL   FOPMS    OF   SUECICAL   TUBERCULOSIS - 

Continued. 

Tuberculosis  of  the  Female  Genital  Organs. — This  disease  is 
of  rare  occurrence.  It  has  only  been  recognized  in  the  last  fe\^ 
years,  before  then  it  was  confused  with  cancer  and  syphilis,  but 
under  modern  researches  it  \\as  found  to  be  tubercular  in  nature. 
It  may  attack  any  portion  vulva,  vagina,  uterus  or  fallopian  tubes. 
"When  the  vulva  is  attacked,  it  resembles  lupus,  it  is  nodular,  un- 
cerative  and  caseous  and  the  bacillus  of  Koch  is  found  in  the 
nodules  on  examinations.  It  sometimes  involves  the  mucous  mem- 
brane of  the  vagina,  tubercular  ulcers  are  formed,  which  show  the 
characteristic  bacillus  on  examination.  TJae  mucous  lining  of  the 
uterus  may  be  attacked,  causing  tubercular  endometritis,  the  lining 
becomes  thickened,  readily  bleeds  and  there  escapes  a  nasty,  fetid 
discharge,  ulcers  form,  followed  by  caseation.  When  the  fallopian 
tubes  become  involved,  the  fimbriated  end  becomes  agglutinated 
and  hermetically  sealed,  the  opening  ioto  the  uterus  also  is  closed 
and  a  saucer  shaped  swelling  is  formed. 


11 


162  PRINCIPLES    OF    SURGERY. 

Cause.  — The  disease  is  always  the  result  of  primary  inoculation, 
it  is  never  secondary  by  extension  from  other  foci.  One  investi- 
gator has  taken  bitches  and  injected  the  bacilli  into  their  vagina 
and  tuberculosis  resulted.  '  Infection  in  women  is  also  due  to  direct 
contact  with  the  germs.  It  is  brought  about  by  their  having  con- 
nection with  men  having  tuberculosis  of  the  penis,  or  even  having 
the  disease  situated  elsewhere,  the  germ  being  carried  in  the  semen. 
The  disease  may  occur  less  directly,  as  by  an  operation  performed 
on  these  parts  by  a  dirty  surgeon  using  contaminated  instruments 
and  sj'ringes. 

Symptoms. — The  symptoms  depend  on  the  anatomical  seat  at- 
tacked. 

Diagnosis. — The  diagnosis  is  based  on  the  appearance  and  can 
be  made  positive  by  the  microscope  or  by  inoculation. 

Prognosis.— The  prognosis  is  good  provided  the  disease  be  taken 
in  its  incipiency  and  properh''  treated,  but  it  is  bad  if  the  disease 
has  existed  for  any  length  of  time. 

Treatment. — The  general  treatment  consist  in  building  up  the 
patient's  general  health  by  administering  tonics,  strychnia.  Cod 
liver  oil,  guaiacol  and  good  nutritious  food.  The  local  treatment 
consist  in  the  radical  extirpation  of  the  diseased  tissue  if  possible. 
If  it  is  on  the  labia,  excise  it;  if  on  the  vaginal  mucous  membrane, 
taKe  out  a  section  of  its  wall;  if  on  the  cervix,  amputate  it;  if  in- 
volving the  raucous  lining  of  the  uterus,  curette  it,  irrigate  and 
pack  with  iodoform  gauze  or  else  perform  a  hysterectomy;  if  the 
fallopian  tubes  are  attacked,  perform  a  laporotomy  and  remove 
them.  When  the  disease  attacks  the  fallopian  tubes,  it  is  impos- 
sible to  diagnose  it  from  Pyosalpiux,  but  both  demand  a  laporo- 
tomy. If  in  doing  an  operation  for  this  disease  or  pyosalpinx,  and 
the  tube  is  found  so  adherent  as  to  be  impossible  to  remove  it, 
split  it  open,  curette  it  and  put  in  drainage. 

Tl'berculosis  of  the  Male  Genital  Organs. — Tuberculosis  of 
the  male  genitals  is  more  frequent  than  of  the  female  genitals,  and 
is  due  to  the  same  causes.  The  disease  may  attack  the  glans  penis, 
urethrae,  epididymis  or  seminal  vesicles.  It  is  usually  a  variety 
of  lupus  \vhen  attacking  the  glans,  it  become?  ulcerative  and 
caseous,  and  on  examination  the  bacillus  of  Koch  is  found.  AVhen 
it  involves  the  urethrae,   it  produces  Tubercular   urethritis;  the 


PRINCIPLES    OF    SURGERY.  163 

whole  mucous  lining  becomes  studded  \^ith  nodules.  When  at- 
tacldng  the  epidid^^mis,  it  is  characterized  b}'-  the  formation  of 
hard  swellings  in  the  scrotum.  The  nodules  are  usually  on  one 
side  only,  they  increase  in  size,  but  cause  no  pain.  If  not  prop- 
erly treated,  the  disease  will  be  rapidly  disseminated,  resulting  in 
death.  When  the  disease  attacks  the  seminal  vesicles,  it  can  be 
diagnosed  by  the  pain  at  the  base  of  the  bladder,  sexual  neurosis, 
by  the  condition  of  the  mind,  and  the  finger  placed  in  the  rectum 
finds  them  enlarged. 

Pkogxosis. — The  prognosis  is  based  on  the  anatomical  location, 
extent  and  pi  ogress  of  the  disease  and  on  the  treatment  applied. 

Treatment. — The  general  treatment  consist  of  the  means  heie- 
tofore  given  to  build  up  the  general  health.  The  local  treatment 
depends  on  the  location  and  extent  of  the  disease.  If  the  disease 
is  on  the  glans  penis,  ainputate  it;  if  the  epididymis  is  involved, 
resort  to  castration  if  only  one  testicle  is  involved,  if  both  are  in- 
volved don't  operate,  not  on  account  of  producing  impotency,  but 
because  the  disease  has  made  such  progress  that  the  operation 
would  be  useless.  When  castrating  for  this  disease,  take  out  all 
the  vas  possible-,  split  open  the  whole  inguinal  canal  up  to  the  in- 
ternal abdoininal  ring,  and  take  out  all  the  cord  possible ;  don't 
ligate  the  cord  as  a  mass,  for  if  you  do  you  will  ligate  one  of  the 
most  sensitive  nerves  in  the  body,  and  the  ligature  will  slip  also, 
causing  death  from  hemorrhage.  Ligate  it  in  numerous  sections, 
and  if  it  bleeds  after  removing  the  forceps,  ligate  again.  When 
the  seminal  vesciles  are  involved,  you  have  a  dilficult  and  hazard- 
ous operation  to  perform.  Make  an  incision  through  the  perineum, 
push  the  prostrate  forward,  the  rectum  backward,  dissect  with 
your  finger  until  you  tincl  the  vescile,  peel  them  off  and  ligate  the 
arteries.  In  performing  the  operation  yoii  are  liible  to  produce  a 
vescial  fistula. 

TuBERCFLosis  OF  THE  Bladder. — Thls  is  a  fairly  frequert  trouble 
and  occurs  either  primarily  or  secondarily.  It  occurs  primarily 
when  the  germ  is  directly  implanted  in  the  bladder  and  first  at- 
tacks its  surface,  and  is  secondary  when  the  disease  extends  tc  the 
bladder  from  a  pre-existing  foci,  as  the  peritoneum  or  vas,  and 
this  form  is  more  hopeless.  The  disease  occurs  more  frequently  in 
women  than  in  men. 


164  PRINCIPLES    OF    SURGERY. 

Symptoms. — ^The  symptoms  come  on  slowly  and  insidiously,  and 
at  first  it  cannot  be  told  from  Cystitis.  There  is  a  feeling  of  weight 
or  heaviness  in  the  pelvis.  He  complains  of  a  burning  sensation 
and  cannot  long  retain  his  urine;  he  can't  go  at  first  a  half  an  hour 
without  micturating,  then  he  has  to  go  every  ten  minutes,  this  is 
because  of  the  inflamed  and  irritative  condition  of  the  bladder. 
Micturition  soon  causes  great  pain  and  spasm  of  the  bladder.  The 
urine  at  first  clear,  in  twenty -four  hours  becomes  cloudy  from 
mucous,  which  normally  is  just  sufficient  to  lubricate  the  surface, 
but  now  makes  up  half  the  urine  and  is  stained  slightly  with  blood. 

Diagnosis. — The  diagnosis  is  based  on  the  family  history,  and 
can  only  be  told  from  cystitis  by  the  microscope  and  by  inoculation. 

Pkognosis.— The  prognosis  is  very  grave,  only  a  few  cases  being 
curable. 

Teeatment. — The  general  treatment  should  be  as  heretofore 
given.  The  paliative  treatment  consist  in  irrigating  the  viscus  two 
or  three  times  dail}^.  Take  an  orrlinary  rubber  catheter,  boil  it 
for  three  or  four  minutes,  l^ow  as  to  the  lubricant  to  use,  some 
recciumend  castor  oil,  carbolized  vaseline  (but  it  has  been  proven 
that  carbolic  acid  in  grease  is  not  antiseptic),  and  neither  do  I  like 
castor  oil,  use  pure  glycerine  as  a  lubricant.  Pass  the  catheter 
gently  into  the  bladder  and  allow  the  viscus  to  empty  itself,  now 
fasten  a  fountain  syringe  to  the  catheter  and  irrigate  with  any  of 
the  following,  having  them  at  a  temperature  of  100  degrees  F. : 
Pnre  water,  normal  saline  solution,  2  percent,  solution  boracicacid, 
Thiersch's  solution  (which  is  salicylic  acid  tv\o  parts,  boracic  acid 
twelve  parts  and  water  to  make  a  thousand),  1  per  cent,  solution 
of  acetate  of  aluminum  or  a  2  per  cent,  solution  of  chloral  hydrate. 
Repeat  the  irrigation  until  the  solution  returns  clear.  With  the 
progress  of  the  disease,  more  radical  measures  must  be  taken ;  make 
him  an  artificial  urethrae;  to  do  this  make  a  suprapubic  incision 
and  allov*'  it  to  heal,  except  at  one  point,  by  this  meatis  he  can 
urinate  without  pain.  One  experimenter  is  removing  the  bladder 
from  dogs,  and  he  says  they  do  well.  He  extirpates  the  bladder 
and  implants  the  ends  of  the  ureters  in  the  rectum,  and  he  claims 
with  the  exception  of  a  slight  dribbling  of  water  in  some  and  diar- 
rhoea in  others  the  dogs  do  well.  This  may  in  the  near  future  be 
applied  to  man.  • 


PRINCIPLES    OP    SURGERY.  165 

Tuberculosis  of  the  Lymphatic  Glands. — This  is  a  very  cora- 
moa  disease,  so  common  is  it  that  j''ou  can't  walk  down  the  street 
over  ten  blocks  without  seeing  two  or  three  cases.  It  is  spoken  of 
by  ihe  laity  and  ignorant  physicians  as  Scrofula  and  treated  with 
Iodine.  They  occur  most  frequently  in  the  cervical  glands,  but 
are  sometimes  seen  in  the  glamls  of  the  axilla.  The}?  give  no 
pain,  but  gradually  enlarge  and  involves  neighboring  glands. 

Causes.— The  essential  cause  is  the  bacillus  of  Koch,  directly 
implanted  in  the  tissues,  or  inherited  if  you  believe  that  theory. 

Patholo&y.-  -A.  person  having  eczema,  a  slight  wound  inflicted 
while  shaping  or  a  decayed  tooth,  has  an  '  ^infection  atrium.''''  The 
germ  ente'^s  through  one  of  the  atriums  and  is  carried  by  the  blood 
to  the  gland.  They  attack  the  gland,  producing  a  chronic  irflam- 
mation,  tubercles  form  and  undergo  caseation  and  finally  the  gland 
is  one  solid  tubercular  mass,  and  soon  other  glands  are  involved. 
If  left  to  nature  unchecked,  one  of  the  glands  will  burst  and  the 
liquified  tubercular  material  escapes  into  the  para-glandular  tissue, 
which  the  germs  attack  and  a  cold  abscess  forms,  which  may  irri- 
gate and  point  under  the  clavicle.  It  soon  ruptures  and  becomes 
infected  by  the  pus  germ,  which  sometimes  causes  death  in  a  short 
while;  again,  from  the  virulency  of  the  infecting  pus  germ ,  the 
whcle  mass  is  changed  into  pus  and  the  patient  is  cured. 

Symptoms. — The  onh^  symptoms  is  a  slow,  painless  enlargement 
of  a  gland  in  the  cervical  region.  Other  glands  soon  become  in- 
volved and  there  is  a  chain  of  enlarged  glands  from  the  back  of  the 
ear  to  the  sternum. 

Diagnosis. — The  diagnosis  is  based  on  the  history  and  confirmed 
by  the  microscope  and  by  inoculation. 

Prognosis. — The  prognosis  depends  oc  the  extent  and  progress 
of  the  disease  and  on  the  ability  of  the  surgeon  consulted. 

Treatment. — The  logical  thing  to  ao  is  to  radically  remove  the 
diseased  gland.  The  operation  is  frequently  performed  with 
brilliant  results,  but  it  takes  a  daring  surgeon,  one  of  ability,  and 
the  anatomy  of  the  neck  with  its  large  blood  vessels  must  be 
known.  Shave  the  neck,  render  everything  aseptic  about  the 
operation,  make  an  incision  parallel  either  with  the  anterior  or 
posterior  border  of  the  Sterno-cleido-mastoid  muscle,  or  make  an 
S -shaped    incision,    commencing   at   the    chin.     Go  through  the 


166  PRINCIPLES    OF    SURGERY. 

Platysma  Myokles  muscle,  and  if  only  the  superficial  glands  are 
involved,  you  can  easilj^  remove  them  \\it.h  the  handle  of  your 
scalpel.  If  the  deep  glands  are  diseased,  cut  the  sterno  cleido- 
mastoid  muscle,  reflect  it,  push  aside  the  arteries,  veins  and  nerves 
and  let  an  assistant  hold  them  out  of  the  ;vay.  Ligate  any  artery 
that  is  necessary  and  cut  the  spinal  accessory  nerve  if  you  find  it 
necessary,  remove  the  glands  thoroughly  or  else  let  them  alone, 
suture  the  sierno-mastoid  muscle,  unite  the  skin,  leaving  in  a 
drainage  tube,  dust  w  ith  iodoform  gauze,  immobilize  the  neck  and 
don't  remove  the  dressings  for  three  vveeks,  unless  there  is  fever, 
pain  or  the  dressings  become  saturated. 


LECTURE  XXXVII, 


CLINICAL   FOE  MS    OF   SURGICAL    TUBERCULOSIS— 

Continued. 

Tuberculosis  of  Bone.  — This  is  a  chronic  inflammation  of  bones, 
due  to  the  specific  bacillus  of  Koch.  It  is  fairly  common,  occur- 
ring next  in  frequency  to  tuberculosis  of  the  lungs  and  lymph 
glands.  It  attacks  all  classes  of  bones,  but  chiefly  the  extremity 
of  long  bones,  though  sometimes  attacking  the  vertebra3,  carpus, 
tarsus  and  bones  of  the  skull.  "When  the  disease  attacks  long 
bones,  it  usually  begins  at  the  junction  of  the  epiphysis  with  the 
diathesis,  this  is  explained  by  the  fact  that  the  bone  is  least  mature 
at  this  point,  new  cells  are  being  formed  and  the  blood  vessels  are 
only  rudimentary. 

Cause, — The  essential  cause  is  the  bacillus  of  Koch.  The  pre- 
disposing cause  is  anything  which  lowers  the  vitality  of  the  bone  as 
a  traumatism  or  injury,  making  a  point  of  least  resistance,  where 
the  germ  finds  suitable  soil  in  which  to  localize  and  propagate. 

Pathology. — The  germ  enters  the  blood  through  some  'Hnfeo- 
tion  atrium,''''  or  from  some  pre-existing  focus,  and  is  carried  to 
some  point  of  least  resistance,  which,  if  in   bone,  is  usually  at  the 


PRINCIPLES    OF    SURGERY.  167 

junction  of  the  diathesis  and  epiphysis.  There  is  chronic  inflam- 
mation set  up,  which  stimulates  the  fixed  cells  to  proliferate  and 
epithelioid  and  giant  cells  are  formed,  leucocytes  are  poured  out 
from  the  now  porous  vessels  and  tubercles  are  formed,  they  soon 
undergo  coagulating  necrosis,  caseation  and  liquifaclion.  Slowly 
and  insidiously  the  focus  enlarges  until  the  periosteum  is  reached, 
this  is  broken  down  and  the  paraperiosteal  tissues  become  involved. 
The  process  now  becomes  rapid,  attacking  fascia,  muscle  and  con- 
nective tissue  and  a  tubercular  abscess  is  formed,  this,  after  bur- 
rowing beneath  the  different  structures,  at  last  opens  and  dis- 
charges through  the  skin 

Symptoms. — The  general  symptoms  are  illy  defined,  and  it  is  often 
taken  for  typhoid  fever.  They  come  on  insidiously  and  do  not 
reach  a  high  intensity,  there  is  a  slight  fever,  characterized  by  con- 
tinuing from  day  to  day  with  slight  intermission,  it  is  of  a  hectic 
type.  There  is  emaciation,  loss  of  strength  and  vigor,  anorexia 
and  a  peculiar  progressive  atiemia.  The  local  symptoms  are  more 
marked,  there  is  pain  about  the  part  which  is  not  acute  and  can 
only  be  found  out  by  questioning  the  patient.  The  pain  is  vari- 
able, it  is  a  boring,  gnawing  pain,  and  not  a  darting  neuralgic 
pain  as  in  suppurative  osteomyelitis;  it  is  pathognomonic  in  this 
disease  for  it  to  have  nocturnal  exacerbations,  it  is  not  severe  enough 
to  awaken  the  child,  but  it  starts  with  a  sharp  cry,  grits  his  teeth 
and  contracts  the  muscles,  and  before  the  mother  reaches  the  bed- 
side is  asleep  again.  The  pain  is  not  always  referred  to  the  seat 
of  the  disease,  as  if  it  is  seated  in  the  upper  third  of  the  femur, 
the  pain  will  be  referred  to  the  kn-^e;  if  in  a  vertebree,  it  will 
be  referred  to  the  stomach.  Tenderness  is  an  important  feature,  it 
not  only  helps  in  locating  the  disease,  but  also  tells  you  the  extent 
to  which  the  disease  has  progressed.  Swelling  is  a  late  symptom, 
not  occurring  until  the  periosteum  has  beeri  perforated.  Eedness 
is  not  present  until  the  cold  abscess  approaches  the  skin,  which 
becomes  first  red  then  livid.  Atrophy  of  the  limb  is  an  invariable 
occurrence,  due  to  non-use  of  the  limb  and  to  the  action  of  toxins 
on  the  trophic  nerves. 

Diagnosis, — The  diagnosis  is  based  on  the  history  and  symp- 
toms. To  approximate  the  size  of  the  diseased  area,  probe  with 
an  aseptic  needle,  when  loss  of  resistance  is  felt,  mark  the  needle, 


168  PRINCIPLES    OF    SURGERY. 

push  it  then  to  the  other  side  and  mark  it  again,  the  distance  be- 
tween the  marks  gives  the  extent  of  the  abscess.  New  use  an 
aspirator,  remove  some  of  the  fluid  and  submit  it  to  a  microscopic 
examination. 

Prognosis. — The  prognosis  is  good,  provided  the  diseased  bone  is 
accessile  to  surgery.  Bone  has  great  resisting  power  and  may  get 
well  spontaneously,  if  not  radical  surgery  will  usually  eradicate  the 
disease. 

Treatment. — The  constitutioQal  treatment  is  that  for  tuberculosis 
in  general.  The  local  treatment  consist  in  giving  the  part  absolute 
rest,  putting  the  diseased  part  in  a  cast  if  necessary  to  accomplish 
it.  If  this  does  no  good,  practice  Igni  puncture,  take  a  red  hot 
iron  or  a  thermo- cautery,  have  it  at  a  white  heat  and  plunge  it 
through  the  tissues  into  the  diseased  bone,  itake  two  or  three 
punctures  if  necessary.  This  does  good  by  giving  drainage,  the 
heat  kills  all  the  germs  it  comes  in  contact  with  and  it  also  stimu- 
lates the  bone  to  plastic  regeneration.  If  this  fails,  use  parenchy- 
matous injections  of  Iodoform.  The  iodoform  does  not  act  so 
much  as  an  antiseptic,  but  it  inhibits  the  growth  of  the  germs.  If 
all  these  methods  fail,  you  must  resort  to  the  knife,  and  when 
once  you  commence  operating  never  stop  until  you  have  radically 
removed  all  the  diseased  tissue.  Eender  the  part  bloodless  and 
aseptic,  cut  through  the  soft  tissues  and  expose  the  bone,  chisel 
through  the  bone  and  remove  the  diseased  tissue  with  a  curette, 
first  removing  the  sequestrium  with  forceps,  sterilize  and  pack  with 
gauze  or  bonetchips.  If  after  cutting  down  en  the  bone,  you  find 
the  disease  too  far  progressed  for  the  above  operation,  resect  a  por- 
tion of  the  bone.     Never  amputate  if  it  is  possible  to  avoid  it. 

TUBEECULOSIS  OF  JoiNTS,    AVhITE    SWELLING    OR  ScROFULOUS  JoiNTS 

are  terms   used   to  designate   an    exceeding  common    tubercular^ 
trouble  involving  articulationo.      It  is  most  frequently  seen  in  the 
knee,  hip,  elbow  and  shoulder  joint,  but  may  occur  in  any  joint. 

Cause. — The  essential  cause  is  the  bacillus  of  Koch.  The  predis- 
posing  cause  is  some  injury  which  lowers  the  vitality  of  the  part. 

Pathology. — The  pathology  is  about  the  same  as  in  tuberculosis 
of  bone.  The  disease  is  either  primary  synovial  or  primary 
osteal;  this  means  the  germ  must  be  implanted  primarily  on  the 
synovial  membrane  when  the  disease  is  called  Primary  Synovitis, 


PRINCIPLES    OF   SURGERY.  169 

or  be  implanted  primarily  on  the  bony  surfaces  of  the  joint  and 
extend  to  the  synovial  membrane,  when  it  is  called  Primary  Osteal 
Synovitis.  After  localization,  there  are  the  characteristic 
changes,  a  chronic  infiaramation,  formation  of  ne\^  cells,  formation 
of  tubercles,  caseation  and  liquifaction.  The  part  becomes  dis- 
tended, the  capsule  ruptures  and  a  cold  abscess  surrounds  the  joint. 

Symptoms. — There  is  hectic  fe\er,  loss  of  flesh,  anorexia  and  pro- 
gressive anemia.  Locally  there  is  swelling.  The  term  white 
swelling,  although  unscientific,  accurately  expresses  the  condition. 
There  is  no  heat  or  redness.  Owing  to  the  swollen  condition  of 
the  joint  and  by  the  muscles  above  and  below  it  becoming  atro- 
phied, the  joint  is  larger  than  any  other  portion  of  the  limb,  and 
the  limb  appears  spindle-shaped.  The  pain  is  variable,  but  has 
the  pathognomonic  nocturnal  exacerbations.  Nature  flexes  the 
joint  to  make  room  for  the  tubercular  matter  and  to  lessen  the 
pain,  and  consequently  there  is  deformity. 

Diagnosis. — The  diagnosis  for  each  joint  mmst  be  studied,  as 
they  differ,  but  the  diagnosis  for  each  is  based  on  the  history  and 
symptoms  and  by  obtaining  some  of  the  fluid  by  aspirating  and 
subjecting  it  to  the  bacteriological  and  microscopic  examination. 

Prognosis. — The  prognosis  depends  on  the  age,  children  giving 
a  better  prognosis  than  adults;  on  the  general  health  and  on 
whether  or  not  the  disease  is  con^ned  to  the  joint. 

Treatment. — Give  tonics,  stimulants,  alteratives  and  good  food. 
Physiological  rest  is  usually  all  that  is  necessary  in  the  first  stage 
to  effect  a  cure.  Coxitis,  diagnosed  early  and  treated  in  this  man- 
ner, is  usually  cured;  put  the  patient  io  bed  and  rest  the  part  by 
pulling  the  head  of  the  femur  out  the  acetabular  cavity  by  weights, 
aiUowing  them  to  swing  over  a  pulley.  If  this  does  not  effect  a 
cure,  aspirate  and  withdraw  the  fluid  and  nature  usually  effects  a 
cure.  After  the  above  fails,  try  tapping,  irrigation  and  iodoformi- 
zation.  Eender  the  part  clean,  cocainize  it,  pass  the  trocar  through 
a  flame  so  as  to  sterilize  it  and  plunge  it  obliquely  into  the  swell- 
ing. Allow  the  fluid  to  escape  through  the  canula,  irrigate  the 
cavity  with  a  Tinct.  Iodine  solution,  inject  about  four  drachms  of 
iodoform  solution  and  seal  the  opening  with  colloidion.  Eepeat 
the  operation  about  every  three  weeks,  and  when  the  swelling  has 
about  subsided,   place  the  limb  in  a  plaster  cast,  so  as  to  give  the 


170  PRINCIPLES    OF    SURGERY. 

joint  physiological  rest.  If  all  the  above  methods  fail  to  effect  a 
cure,  you  must  resort  to  more  radical  methods.  Do  a  resection, 
don't  hesitate  to  open  the  joint.  Tlender  the  limb  bloodless,  and 
make  an  incision  down  to  the  patella  if  it  is  the  knee  joint  dis- 
eased, sa\^  this  in  two,  cut  the  lateral  ligaments,  and  with  a  rat 
tooth  forceps  au<l  a  pair  of  scissors  remove  the  s3''novial  mem- 
brane. If  the  bone  is  involved,  curette  it;  follow  out  all  the  rami- 
fications of  the  disease  and  remove  the  infected  tissue.  When  the 
joint  is  opened  and  the  disease  found  to  have  progressed  too  far  to 
expect  to  get  a  fairly  good  joint  from  the  above  operation,  resect 
the  end  of  the  bones,  pin  them  together  with  bone  pins  and  give 
the  patient  a  stiff  joint.      As  a  last  resort  to  save  life,  amputate. 


LECTURE    XXXVIII. 


RICKETS— HEMOPHILIA— HYSTERIA, 

Rickets  or  Rhachitis.— This  disease  was  discovered  by  the 
English  in  1850  and  was  called  English  disease.  It  is  a  constitu- 
tional disease,  characterized  by  distortion  of  the  skeleton.  The 
disease  is  very  common  in  Europe  among  the  lower  classes,  but  in 
America  where  sunshine  and  fresh  air  is  plentiful, where  better 
hygenic  environments  exipt,  the  disease  is  rarely  seen,  and  then 
onl}^  in  negroes  and  poor  white  people. 

Causes. — Heredity,  improper  food  and  bad  hygenic  surround- 
ings cause  the  disease.  Some  observers  claim  the  disease  is  hered- 
itary; that  it  is  transmitted  from  parent  to  offspring.  This  is  not 
so;  it  is  true  it  is  often  seen  running  through  a  whole  family,  the 
first  children  will  be  healthy,  but  the  younger  ones  have  rickets. 
This  is  because  the  first  children  receive  better  food,  more  fresh  air 
and  more  clothing  than  the  younger  ones,  simply  because,  as  the 
family  grows  larger,  from  proverty,  the  food  and  clothing  gro\^ 
worse  and  the  house  becomes  more  crowded,  and  consequently  the 
h3^gienic  surroundings  are  not  as  good.     The  most  essential  cause 


PRINCIPLES    OF    SURGERY.  171 

is  improper  food,  especially  when  it  is  deficit  of  lime  salts.  This 
has  been  proven  by  experiments  on  young  lions,  ^i  hen  they  were 
fed  exclusively  on  lean  meat,  rickets  developed;  and  monkeys  fed 
on  skimmed  milk,  without  lime  salts,  also  developed  the  disease, 
and  were  cured  by  feeding  them  on  good  food  containing  lime 
salts.  You  will  never  see  rickets  in  a  nursing  baby,  because  the 
mother's  milk  contains  the  proper  salts;  it  is  seen  in  children  fed 
on  cow's  milk  and  artificial  food. 

Pathology. — The  pathology  merely  consist  of  defective  deposits 
of  lime  salts  in  bones.  When  a  child  is  born,  its  bones  are  soft 
and  elastic,  as  it  grows  nature  deposits  lime  salts  in  them  which 
causes  them  to  become  hard  and  strono;.  In  rickets  nature  can't 
do  this  on  account  of  the  deficiency  of  the  salts  in  the  blood. 
Curves  are  normally  found  in  bones,  caused  by  muscular 
contraction,  but  in  rickets  they  are  exaggerated  and  sometimes 
approaches  deformit}^,  caused  b}^  the  ^\'eight  of  the  body  on  the 
soft  pliable  bones. 

Symptoms. — The  shape  of  the  head  is  peculiar.  It  is  long  and 
narrow  at  the  forehead,  sharp  chin  and  the  sternum  is  usually  de- 
formed, with  a  row  of  bumps  running  along  each  side  of  it.  The 
pelvis  is  deformed  from  the  iliac  bones  being  pushed  out  by  the 
mechanical  weight  of  the  body.  The  limbs  are  distorted;  if  the 
child  crawled  at  an  earl}^  age,  the  elbows  will  be  bent;  the  knees 
are  averted,  due  to  relaxation  of  the  joint  and  to  pressure;  the 
digestion  is  poor,  the  stomach  not  having  had  proper  food,  when 
it  is  given  to  the  patient  it  is  not  digested  and  flatulence  and  diar- 
rhoea follow. 

DiAGxosis. — The  diagnosis  is  based  on  the  symptoms,  the  shape 
of  the  head,  bumps  on  the  side  of  the  sternum,  arms  and  legs 
bowed,  diarrhoea  and  indigestion. 

Feognosis. — The  prognosis  is  based  upon  your  ability  to  place 
the  child  in  better  surroundings. 

Tkeatmext.  --Put  your  patient  in  the  best  possible  surrounding, 
send  him  to  the  seashore,  Dse  massage,  hot  bath,  clothe  in  flannels 
and  give  him  plenty  of  good  food  and  fresh  air.  If  it  is  a  baby 
employ  a  wet  nurse;  if  too  old  for  this  feed  it  on  cream  and  milk 
sugar,  and  if  it  is  old  enough  feed  on  beef  steak  and  vegetables. 
Medicines  do  not  accomplish  much.      Some  recommend  the  admin- 


172  PRINCIPLES    OF    SURGERY. 

istration  of  lime  salts,  but  on  account  of  their  not  being  digested  or  as- 
similated they  do  little  good.  Give  tonics  to  build  up  the  general 
health,  such  as  iron,  etc.,  but  the  most  Important  treatment  is  the 
proper  hy genie  surroundings  and  good  food.  This  treatment  does 
not  cure  the  existing  deformity,  but  prevents  it  from  becoming 
worse,  and  the  growth  of  the  child  may  correct  the  primary  de- 
formity. Sometimes  the  deformity  is  so  great  as  to  demand  sur- 
gical interferences.  If  the  child  is  young  you  can  reduce  the  de- 
formity by  manipulating  the  limb  with  the  hands  until  the  limb  is 
straight  and  then  applying  a  splint  for  some  time.  If  the  child 
is  too  old  for  this  and  the  deformity  is  great  enough  to  justify  it, 
make  an  incision  through  the  skin,  lay  bare  the  bone,  and  with 
a  chisel  and  mallet  strike  the  bone  a  sharp  blow,  set  it  as  a  frac- 
ture, put  on  a  plaster  cast  and  let  it  remain  six  weeks. 

Hemophilia  ok  Bleeders  Disease. — This  is  a  constitutional  dis- 
ease, characterized  by  a  tendency  to  excessive  bleeding  from  trivial 
causes.  The  disease  is  fairly  frequent,  being  met  with  by  a  busy 
surgeon  about  once  a  year.  It  is  exceedingly  dangerous  to  operate 
on  such  patients.  It  is  found  nine  times  oftener  in  men  than  in 
fvomen. 

Cause.—  The  cause  is  absolutely  unknown.  There  is  no  morbid 
anatomy  or  characteristic  symptoms,  you  can  only  tell  them  by 
cutting  them.  The  condition  seems  to  be  hereditary,  some  claim 
that  it  is  the  most  hereditary  of  all  hereditary  diseases.  It  is 
transmitted  from  mother  to  son,  this  is  peculiar;  if  a  woman  has 
six  children,  three  girls  and  three  boys,  the  boys  will  be  bleeders 
and  the  girls  will  not,  but  the  girls  sons  will  be  bleeders,  and  the 
sons  of  the  boys  will  not. 

Symptoms. — There  are  no  symptoms  except  bleeding  on  all  occa- 
sions from  trivial  injuries.  The  bleeding  is  not  so  profuse,  but  is 
continuous.  It  is  neither  arterial  or  venous  in  character,  but  sim- 
ply welds  up  from  the  capillaries.  The  inflicted  individuals  can't 
be  recognized,  as  they  may  be  pale  or  ruddy. 

Treatment. —Take  the  time  and  ask  every  patient  before 
operating  on  them,  if  he  is  a  bleeder  or  if  any  of  his  family  are 
bleeders,  if  he  answers  in  the  afiiriiiative,  don't  operate.  When  a 
bleeder  is  injured  or  cut,  all  you  can  do  is  to  use  styptics  and 
pressure.     You   can't   ligate  the  artery,  for  the  wound  you  make 


PRINCIPLES    OF    SURGERY.  173 

will   bleed   as  much  as  the  first  \^ound,  neither  can  you  use  acu- 
pressure. 

HYSTERiA.--Hysteria  inay  be  defined  as  an  instability  of  the 
nervous  system,  due  to  lack  of  control.  It  is  the  inability  of  an 
individual  to  regulate  the  manifestations  of  nervous  phenomena, 
influenced  by  \arious  stimuli.  Sometimes  a  maximum  stimulus 
will  produce  little  effect,  again  a  minimum  stimulus  will  produce  a 
Kaximum  result.  It  is  frequently  met  with,  there  will  not  be  a 
da}^  in  your  practice  that  your  diagnosis,  prognosis  and  treatment 
will  not  be  confused  by  it.  Hysteria  is  really  a  disease,  and  people 
who  suSer  from  it  deserve  your  sympathy  and  support. 

Causes.- — There  is  no  condition,  race,  age  or  sex  that  is  free  from 
the  disease,  it  is  seen  in  the  young  and  in  the  aged,  in  the  intelli- 
gent and  in  the  fool.  It  is  more  frequent  from  fifteen  to  twenty 
years  of  age,  but  may  occur  any  time  in  life.  In  w^omen  about 
the  time  of  the  full  development  of  their  sexual  organs,  their  desires 
are  not  gratified  and  consequent  neurosis,  it  is  frequent.  It  is 
more  com m. on  in  the  women  than  in  the  men,  the  word  Hysteria 
tells  jou  this.  Hj'^steria  was  the  name  used  by  the  ancients  because 
they  thought  it  was  due  to  some  defect  in  the  wom  b.  Heredity 
can't  generally  be  traced  directly,  but  sometimes  whole  families  are 
neurotic.  Diseases  of  the  generative  organs  is  a  common  cause, 
as  an  inflamed  ovary,  endometritis,  displaced  uterus,  hydrocele  and 
varicocele.  Anemia  or  lack  of  red  blood  corpuscles  will  cause  it, 
but  is  readily  cured  by  restoring  the  corpuscles.  Dyspepsia  is  a 
frequent  cause.  Work,  worry  and  whiskey  combined  will  cause 
it,  if  these  three  conditions  don't  cause  it,  add  the  fourth,  a  wife, 
and  you  have  all  the  essentials.  Work  without  worry  will  not 
cause  it. 

Sy^^iptoms. — You  can't  classify  the  symptoms;  sometimes  they 
appear  in  one  way,  sometimes  in  another;  they  are  truly  like  the 
Irishman's  flea,  you  can't  tell  how  they  are  coming.  Tne  psychical 
condition  is  horrible.  They  carry  everj''  action  of  the  body  through 
an  analysis,  they  critically  examine  everything  they  eat  and  can 
describe  in  minutest  detail  its  pans  and  constituents.  They  know 
more  about  the  alimentary  canal  than  the  doctor,  having  read 
every  quack  pamphlet  the}^  can  find;  they  dissect  with  repulsive 
boldness  everj?    evacuation  from  the  bowels  and  describe  them  to 


174  PRINCIPLES    OF    SURGERY. 

vou  with  disgusting  forwardness.  Their  sensory  organs  may  be 
rendered  peculiarly  keen  and  sensative.  They  ca^n't  stand  odors, 
a  stra IV berry  v/iil  make  then  faint.  Light  blinds  them.  There 
may  be  hyperasthesia  or  anesthesia,  motor  paralysis,  hemiplegia, 
paraplegia  and  aphonia  (until  you  make  them  mad).  There  may 
be  unconsciousness,  globus  hystericus  or  ball  in  the  throat,  diarrhoea 
or  constipation,  bladder  palsy,  can't  hold  their  vsater  and  may  pass 
as  much  as  a  half  a  gallon  of  urine  in  an  hour,  their  face  may  be 
pale  or  flushed  and  the  menstruation  increased  or  diminished. 
They  sometimes  simulate  surgical  diseases,  as  a  hysterical  knee, 
hysterical  spine  or  phantom  tun] or.  They  will  have  some  sexual 
trouble  and  here  your  ingenuity  is  taxed,  they  imagine  they  have 
some  venecal  disease,  and  will  discuss  it  and  prove  to  you  that  they 
are  right.  They  suffer  from  spermatorrhea  and  have  been  reading 
some  quack  book  about  it  and  you  can't  tell  them  anything,  they 
are  versed  in  all  that  pertains  to  the  trouble. 

Tkeatment. — The  treatment  requires  tact,  common  sense  and  a 
strong  personality.  Inspire  the  patient  w  ith  a  moral  tone  that  may 
overcome  the  uncontrollable  nervous  condition.  Gain  the  confi- 
dence and  trust  of  your  patient  and  use  it  to  his  cure.  Drugs  do 
no  good  unless  they  smell  and  taste  oadly,  and  the  drugs  recom- 
mended are  good  only  on  this  account.  lajudicious  sympathy  is 
tvhat  does  harm.  Don't  be  needlessly  rough,  but  keep  on  hand  a 
supply  of  both  sympathy  and  roughness,  and  if  you  can't  gain 
their  confidence  in  three  days  by  sympathy,  then  make  them  fear 
you.  The  surgical  treatment  consist  of  an  operation  which  makes 
a  mental  impression  on  the  patient,  as  in  a  phantom  tumor,  give 
them  chloroform,  make  an  incision  through  the  skin,  sew  it  up, 
put  them  in  bed  and  have  a  nurse  to  take  their  temperature  every 
twenty  minutes  and  starve  them  for  three  days. 


PRINCIPLES    OF    SURGERY.  175 


LECTURE  XXXIX. 


SYPHILIS. 

Syphilis,  Pox  or  Lues,  is  a  ooDstitutioaal  disease,  due  to  a  specific 
virus  and  is  characterized  by  the  formation  of  a  local  ulcer,  which 
is  followed  by  definite  constitutional  symptoms.  The  history  of 
the  disease  is  of  great  interest.  The  first  classical  treatise  on  the 
subject  appeared  in  the  fifteenth  century.  A  bout  this  time  there 
1^  as  an  epidemic  of  the  disease  in  Europe.  By  the  compilers  of 
this  work,  the  origin  of  syphilis  in  Europe  was  credited  to  America; 
they  maintained  that  its  home  was  among  the  Indians  of  America, 
and  that  its  occurrence  in  the  old  country  was  brought  about  by 
the  return  of  sailors,  who  became  inoculated  on  American  shores, 
but  the  disease  has  a  more  lengthy  pedigiee.  Many  of  the  old 
records  of  Leprosy  ha\e  been  proven  to  have  been  syphilis,  and  a 
more  perfect  and  accurate  reading  of  the  ancient  scrolls  and  manu- 
scripts have  developed  the  undoubted  truth  that  the  disease  existed 
in  its  most  malignant  form  among  the  Egyptians  and  Chinese  3,000 
years  B.  C.  There  are  three  conditions  which  can  arise  from  im- 
pure coitus,  Gonorrhea,  Chancroid  and  Chancre.  Gonorrhea  is  a 
suppurative  infl.ammation  attacking  the  urethrea,  due  to  a  specie 
germ.  It  is  entirely  a  local  disease  and  yields  readily  to  treatment. 
Chancroid  is  a  phagedenic  ulcer,  an  eating  sore,  due  to  the  inocu- 
lation of  a  specie  virus.  It  is  entirely  a  local  disease,  and  v^^hen 
the  sore  is  cured  the  patient  is  well.  Chancre  is  entirely  different 
from  the  above.  It  commences  as  a  local  ulcer  at  the  point  of 
inoculation,  but  the  poison  is  soon  diffused  throughout  the  entire 
system  a  ad  is  difficult  to  eradicate.  In  the  days  of  John  Hunter, 
these  three  diseases  were  looked  upon  as  one  and  the  same,  v^ere 
treated  alike  and  consequently  many  victims  died  from  inproper 
treatment.  But  John  Hunter,  the  great  surgical  philosopher, 
thought  he  saw  a  difference  in  the  diseases.  He  finally,  from 
observations  and  experiments,  stated  before  a  society  his  views. 
He  was  hooted  at,  but  he  said  he  would  prove  his  assertions  by 
inoculating  sonae  of  the  pus  of  gonorrhea  into  his  own  arm.     He 


176  PRINCIPLES    OF    SURGERY. 

proceeded  to  the  stage  and  against  the  protest  of  his  friends  inocu- 
lated some  of  the  pus  into  his  arm,  Unforluoately  for  John  Hun- 
ter and  science,  the  individual  from  whom  the  pus  was  tal^en  was 
infected  with  both  gonorrhea  and  syphilis,  a  chancre  developed  on 
his  arm  and  he  ultimately  died  of  sj^philis.  He  turned  apostate 
by  this  seemingly  convincing  evidence  and  said  he  was  wrong.  For 
fifty  years  no  one  had  the  audacity  to  qnestion  the  matter,  but 
after  that  time  one  of  John  Hunter's  followers,  named  Ricord, 
announced  that  there  was  a  difference  and  by  careful  experiments 
proved  that  there  was  one  kind  of  chancre  which  was  followed  by 
constitutional  symptoms  andariother  kind  which  was  entirely  local. 
The  first  kind  he  called  hard  chancre  and  and  the  latter  was  called 
soft  chancre.  Bassereau,  the  nej^t  investigator,  proved  by  experi- 
ments that  the  soft  chancre  was  not  syphilis  at  all,  but  a  chancroid. 
"When  syphilis  was  first  written  about  in  the  fifteenth  century,  it 
was  very  malignant.  Charles  VIII.  was  carrying  on  a  campaign 
at  tne  time  and  one-half  of  his  soldiers  died  from  syphilis,  forcing 
him  to  abandon  his  project.  The  disease  was  so  virulent  that  those 
afflicted  with  it  only  lived  a  year,  and  then  their  nose,  cheeks  and 
ears  were  eaten  away.  But  syphilis  has  become  more  and  more 
attenuated,  until  to-day  it  is  comparatively  harmless.  Although 
the  diseasts  is  much  less  dangerous,  when  you  inform  a  patient  that 
he  has  syphilis,  he  is  horribly  frightened  from  the  records  he  has 
read  of  its  past  malignancy.  The  question  is  frequently  asked 
wh}'^  the  disease  has  become  mild.  It  is  because  in  these  modern 
times  we  have  better  hygienic  surroundings,  better  food,  clothes 
and  houses.  We  have  better  doctors,  we  do  not  salivate  and  not 
only  is  the  above  true,  but  the  disease  is  milder  ^from  being  so 
thoroughly  disseminated  among  the  people,  giving  us  somewhat  of 
an  immunity  against  it  by  an  attenuated  portion  of  the  virus  being 
in  our  blood  by  inheritance.  This  has  been  demonstrated  to  be 
true.  In  Africa  the  disease  was  unknown  until  the  white  man 
appeared  on  its  shores.  The  white  man  implanted  it  there,  and 
it  worked  a  most  deadly  and  malignant  progress  on  the  negroes, 
while  the  white  man,  having  it  at  the  same  time,  had  only  a  mild 
form.  The  principle  was  also  established  in  other  diseases.  Measles 
was  unknown  in  the  Sandwich  Islands  until  brought  by  mission- 
aries, when  it  attacked  the  natives  and  killed  nearly  two-thirds  of 


PRINCIPLES    OP    SURGERY.  177 

them,  while  in  this  country,  where  the  disease  has  raged  for  years, 
death  seldom  occurs.  All  these  facts  go  to  show  that  an  immunity 
maybe  established  by  inheritance.  The  frequency  of  this  disease  is 
a  subject  I  loath  to  discuss.  As  students  you  do  not  know  how 
common  it  is,  as  practitioners  you  will  be  fully  impressed  with  its 
prevalence.  The  frequency  as  given  in  text-books  vary,  some  state 
that  in  the  United  States  one  person  out  of  every  twenty  has  the 
disease,  while  others  ■  state  that  it  is  one  out  of  every  five.  The 
importance  of  a  disease  so  prevalent  can't  be  over-estimated. 
Usually  when  called  to  a  patient,  your  responsibility  only  rests 
with  the  patient,  but  in  this  disease  you  have  to  look  out  for  the 
wives  and  children,  and  also  have  to  decide  the  advisability  of 
marriage. 

Cause. — Syphilis  is  due  to  a  specific  virus,  this  means  it  is  due 
to  some  vague  poison  which  has  not  been  discovered.  The  reason 
the  germ  has  net  been  isolated  is  because  man  is  the  only  animal 
that  can  be  inoculated,  he  is-  sole  heir  to  the  disease,  and  therefore 
no  direct  investigations  can  be  made.  One  observer  claims  he  hiLS 
produced  the  disease  in  monkeys;  this  is  probably  not  so,  as  he 
was  working  trying  to  prove  his  theory  of  evolution  and  not  try- 
ing to  isolate  the  germ  of  the  disease.  If  syphilis  hasn't  been 
proven  to  be  of  microbic  origin,  why  do  I  feel  justifiable  in  saying 
it  is  due  to  a  specific  germ?  Because  sj^philis  so  closely  resembles 
those  diseases  which  have  been  proven  to  b^  due  to  a  germ;  it  re- 
sembles them  in  being  contagious,  can  be  transmitted  from  a  dis- 
eased to  a  h3althy  person,  in  having  a  period  of  incubation;  it  is 
accom pained  by  an  eruption,  in  having  a  peculiar  set  of  sequelae, 
and  lastly  by  one  attack  immunizing  the  individual  from  subse- 
quent attacks.  From  this  consistent  chain  of  analogy,  we  say 
syphilis  is  due  to  a  germ,  and  the  day  is  not  far  distant  when  it 
will  be  discovered,  provided  our  Legislature  will  deem  ii  of  suffi- 
cient importance  to  contribute  the  condemned  criminals  to  science. 

Tathology.  —No  two  observers  follow  the  same  lines  in  regard 
to  the  pathology,  and  I  will  take  the  bull  by  the  horns  and  say 
the  pathology  is  unknown  and  will  not  be  known  until  the  germ  is 
discovered,  when  it  can  be  accurately  written. 

Methods  of  Transmission. — Syphilis  may  be  either  hereditary  or 
acquired.     Hereditary  syphilis  is  due  to  one  or  both  parents  hav- 

12 


178  PRINCIPLES    OF    SURGEP.Y. 

ing  the  disease  and  from  them  is  transmitted  to  their  offspring. 
This  subject  will  be  discussed  in  a  future  lecture.  Acquired 
syphilis  is  due  to  inoculation  after  birth.  There  are  certain  pro- 
ducts which  contain  the  virus.  It  was  fornierlj  thought  that 
everything  about  an  infected  person  could  transmit  the  disease, 
tears,  semen,  saliva,  etc.  This  is  not  true,  the  only  products  which 
can  produce  the  disease  are  the  secretions  from  the  chancre  or 
original  lesion,  this  is  the  nost  important  and  severe;  the  secre- 
tions from  mucous  patches  or  small  ulcers  on  the  skin  or  mucous 
membrane  and  lastly  the  blood.  If  any  of  the  normal  secretions 
produce  the  disease,  it  is  because  the  secretions  from  a  chancre, 
mucous  patch  or  blood  is  mixed  with  it.  As  by  kissing  an  infected 
individual,  the  disease  is  transmitted  from  the  secretions  of  the 
ulcers  in  the  mouth  being  mixed  with  the  saliva;  or  if  transmitted 
from  the  milk  of  the  mother  to  the  child,  it  is  because  there  is  an 
ulcer  on  the  nipple,  and  if  contracted  from  coitus,  it  is  not  due  to 
the  semen  containing  the  germ,  but  there  is  an  ulcer  in  the  urethrae 
and  its  secretion  becomes  mixed  with  the  semen.  The  use  of  vac- 
cine virus  obtained  from  the  scab  on  a  person  vaccinated  was 
ttought  to  cause  the  disease,  and  a  great  uproar  was  raised  some 
years  ago  and  societies  were  formed  to  prevent  the  use  of  the  virus 
obtained  in  this  manner;  further  investigation  proved  that  the  dis- 
ease was  not  produced  from  the  virus,  but  because  the  scab  was 
carelessly  removf^d  and  blood  from  the  individual  was  contained  in 
it,  thus  causing  the  disease.  The  invention  of  vaccine  points  have 
done  away  with  the  cranks  who  opposed  the  Qriginal  method.  The 
fact  that  the  blood  of  syphilitics  contains  the  virus  and  is  inoculable 
is  important  to  surgeons,  for  thousands  cf  them  have  contracted  the 
disease  while  op*^iating  through  a  slight  abrasion  or  by  accidentally 
cutting  themselves.  The  virus  or  germ  cannot  enter  the  unbroken 
skin  or  mucous  membrane,  there  must  be  an  ^Hnfeotion  atrium^'''' 
and  wherever  the  lesion  or  abrasion  occurs,  and  the  germ  enters,  a 
chancre  is  formed  at  that  point;  as  a  person  having  a  crack  on  the 
lip,  hair  cut  on  the  penis,  or  hang  nail,  and  the  part  comes  in  con- 
tact with  the  virus,  a  chancre  will  be  formed  at  the  site  of  tne  lesion. 
There  are  two  ways  of  inoculation  by  syphilis.  Immediate  or 
direct  infection  and  Mediate  or  indirect  infection.  Direct  infection 
is  the  most  common,  and  is  caused  by  an  abraded  surface  coming 


PRINCIPLES    OF    SURGERY.  179 

in  contact  with  the  blood  ol:  a  syphilitic  person  or  the  secretions 
froiE  a  chancre  or  mucous  patch.  The  most  frequent  site  of  inocu- 
lation is  the  penis,  caused  by  having  an  abrasion  on  the  organ, 
which  becomes  infected  by  having  connection  with  a  sj^philitic 
woman.  Indirect  infection  is  the  innocent  way  and  the  way  which 
all  claim  to  ha"^e  acquired  the  disease.  The  virus  is  not  conveyed 
directly,  but  there  is  some  in  between  media,  as  a  drinking  glass, 
seat  of  a  water  closet,  a  pipe  smoked  by  a  number  of  persons,  and 
by  catheters,  towels  and  sponges  which  were  not  properly  steril- 
ized. However  vague  these  stories  are,  there  is  a  probability  of 
this  beiao:  true.  There  is  on  record  an  instance  where  an  old  raid- 
wife  contracted  syphilis  in  her  occupation  and  a  chancre  developed 
on  her  finger.  Although  the  disease  was  diagnosed,  she  did  not 
stop  her  work  until  arrested,  when  it  was  found  out  that  she  had 
inoculated  forty-seven  women.  She  was  imprisoned  for  life. 
Another  case  is  reported  where  a  man  who  had  a  long  prepuce, 
met  his  old  mistress  and  had  connection  with  her.  He  carried  the 
hidden  virus  to  his  wife,  she  contracted  the  disease  and  he  escaped 
his  just  punishment.  A  similar  case  is  reported  where  a  married 
woman  had  connection  with  an  old  lo\er,  and  soon  afterwards  she 
had  connection  with  her  husband,  she  escaped,  but  the  husband 
bore  on  his  body  the  souvenir  of  the  lovers'  meeting. 

Immujv^ity.^ — Immunity  to  syphilis  may  be  acquired,  first,  by  hav- 
ing a  genuine  case.  This  gives  absolute  immunity.  There  is  on 
record,  "where  individuals  have  had  the  disease  twice,  but  doubts 
^  ere  raised  if  the  first  attack  was  really  a  genuine  case  of  syphilis. 
Second,  Colle's  immunity.  This  is  the  immunity  the  mother  has 
after  giving  birth  to  a  syphilitic  child,  fathered  by  a  syphilitic  man. 
For  instance,  a  syphilitic  man  marries  a  healthy  woman;  their 
children  will  be  syphilitic,  but  the  wife  will  not  be  infected,  and 
father  will  be  immune  against  the  disease.  Third,  Profeta's  im- 
munity. This  is  the  freedom  or  immunity  which  a  person  has, 
due  to  their  father,  mother  or  some  of  their  forefathers  or  mothers 
having  the  disease.  As, a  man  having  syphilis,  his  child  will  have 
the  disease  in  a  milder  form,  and  his  child's  children  will  be  im- 
mune or  have  a  stili  milder  form  of  the  disease,  and  so  on  down  for 
generations,  until  perhaps  his  grandchildren  v\/ill  be  absolutely  im- 
mune. 


180  PRINCIPLES    OF    SURGERY. 

(Ilinical  History  of  a  Typical  Unteeated  Case  of  Syphilis. — 
There  are  three  stages  of  syphilis,  primary,  secondary  and  tertiary. 
Each  of  the  stages  are  preceded  by  a  period  of  iocubation,  so  vir- 
tual] v"  there  are  six  stages.  A  man  has  connection  with  a  syphilitic 
woman,  and  during  the  process  abrades  the  head  of  his  penis  and 
is  inoculated.  He  goes  home  and  sees  the  bleeding  point,  washes 
it  and  in  two  or  three  days  it  heals  and  he  thinks  no  more  about 
it.  In  three  weeks  a  chancre  develops  at  the  point  of  the  abrasion. 
It  is  a  hard,  indurated  lump,  which  grows  and  gets  as  large  as  a 
filbert.  Lines  are  seen  running  up  the  penis  and  the  glands  in  the 
groin  are  tender  and  sore.  The  period  from  the  time  of  inocula- 
tion to  the  formation  of  the  primary  lesion  or  chancre,  is  the 
primary  period  of  incubation,  and  from  that  time  to  the  subsi- 
dence of  the  above  symptoms,  is  the  primary  stage  of  syphilis, 
which  usually  last  about  one  or  two  months.  After  the  subsidence 
of  the  above  symptoms,  the  chancre  and  bubo  disappearing,  the 
second  period  of  incubation  comes  on  and  lasts  about  sis  weeks. 
After  the  elapse  of  the  above  time,  the  secondary  stage  appears. 
He  has  little  fever,  is  restless,  disturbed,  head  ache,  backache  and 
he  thinks  perhaps  he  has  caught  cold.  On  arising  one  or  two 
morrings  after  the  above  symptoms  appear,  he  finds  an  eruption 
on  his  chest,  which  looks  like  the  eruption  of  measles,  his  throat 
is  soie,  he  is  hoarse,  and  with  a  looi^ing  glass  he  discovers  ulcers  in 
his  throat.  Mucous  patches  form  on  th^  gums,  in  the  axilla  and 
groin  and  from  them  comes  a  foul  discharge.  His  eyes  are  red 
and  sensitive  to  light,  his  hair  falls  out  from  his  head,  eye  lashes 
and  pubis.  These  symptoms  now  get  better  and  the  third  period 
of  incubation  comes  on,  which  lasts  a  vfxiable  length  of  time,  when 
the  tertiary  stage  appears.  There  are  deposits  of  gummata  or 
nodules  in  all  the  tissues  of  the  body,  upon  bone  tissue,  in  the  brain 
or  spinal  cord,  in  the  heart,  liver  and  kidneys  and  on  the  skin. 
These  deposits  ulcerate  and  if  situated  on  the  face,  they  eat  away 
the  cheek  and  nose,  even  exposing  the  teeth,  nervous  symptoms 
developed,  suppuration  sets  in,  he  is  a  disgusting  object  and  dies 
a  slow  and  painful  death. 


PRINCIPLES    OF    SURGERY.  181 


LKCTURE   XL. 


SYPHILIS— CONTIND  ED. 

SYMPTOMS  OF  ACQinRED  SYPHILIS.— Acquired  syphilis 
is  divided  into  three  stages,  priiiiar}',  secondary  and  tertiary. 
Each  staofe  is  preceded  by  its  corresponding  period  of  incubation. 

PPJMARY  SYPHILIS.— This  is  the  stage  of  the  chancre  and 
bubo.  It  has  a  period  of  incubation,  that  is,  after  inoculation  or 
after  a  suspicious  intercourse,  no  symptoms  develop  in  from  two 
to  six  weeks  (average  time  three  weeks).  At  the  expiration  of  this 
time  there  comes  on  definite  symptoms,  ^\hich  result  in  the  for- 
mation of  a  chancre  and  bubo.  A  chaxcre  is  the  primary  lesion 
of  syphilis.  It  consist  of  a  nodule  which  forms  at  the  site  of  inocu- 
lation. It  is  usually  seen  on  the  penis  in  the  male  and  on  the 
labia  in  the  female,  but  may  appear  anywhere,  as  in  surgeons  it 
appears  usually  on  the  finger,  that  being  the  most  frequent  site  of 
inoculation.  There  are  three  varieties  of  chancre,  superficial,  deep 
and  phagedenic.  Do  not  think  this  means  there  is  a  difference  in 
kind,  all  are  due  to  the  same  specific  virus,  and  are  followed  by 
constitutional  symptoms,  but  they  differ  in  type  and  degree,  due 
to  the  different  resisting  power  of  the  different  tissues  to  the  action 
of  the  virus.  The  same  woman  may  give  different  men  any  of  the 
varieties.  The  SuPEfiFiciAL  Chancre  is  the  most  common  type. 
Out  of  170  cases  it  occured  l-IO  times.  It  deserves  its  name  from 
the  depth  it  penetrates.  It  appears  first  as  a  macule  and  then  be- 
comes a  papule.  Before  going  any  further,  it  is  better  to  define 
four  terrcs  we  shall  use:  A  macule  is  a  discoloration  of  the  skin 
which  is  not  elevated;  a  papule  is  a  discoloration  of  the  skin  which 
is  elevated;  a  vesicle  is  an  elevation  of  the  skin  filled  with  water; 
a  pustule  is  an  elevation  on  the  skin  filled  \^ith  pus.  The  papule 
of  a  superficial  chancre  is  solid,  of  a  peculiar  red  copper  color,  and 
the  r.kin  over  it  often  desquamates  or  becomes  scaly.  The  papule 
develops  at  the  point  of  inoculation,  increases  in  size  until  it  reaches 
the  size  of  an  ammond;  the  skin  then  becomes  broken,  a  watejy 
discharge  comes  from  it  and  an  ulcer  is  formed.     The  papule  has 


182  PRINCIPLES    OF    SURGERY. 

a  parchment  like,  indurated  feeling  when  taken  between  the 
fingers.  The  Deep  or  Hunterian  Chancre  is  different  from  the 
above.  Tt  extetids  deep  into  the  tissues,  and  is  of  rare  occurrence. 
It  forms  as  a  macule,  becomes  a  papule,  which  undergoes  ulcera- 
tion, and  a  deep  ulcer  forms,  with  sloping  margins,  protrudes  above 
the  surface  of  the  skin  and  is  bathed  in  a  nasty  pus.  It  is  indu- 
rated like  the  superficirJ  chancre,  but  instead  of  feeling  like  parch- 
ment, it  feels  like  a  «plit  pea.  The  Phagedenic  Chancre  is  noth- 
ing but  one  of  the  preceding,  which  has  become  infected  with  a 
poison  which  causes  an  eating  sore.  It  is  sometimes  spoken  of  as 
a  migrating  chancre,  as  it  eats  into  the  neighboring  tissues,  as  if 
it  is  situated  on  the  penis,  it  w^ill  extend  entirely  around  the  organ. 
All  of  the  above  varieties  of  chancre  are  due  to  the  same  cause, 
their  difference  depends  on  the  resisting  power  of  the  tissue  at- 
tacked. The  induration  of  a  chancre  is  characteristic.  In  all  in- 
flammations there  is  some  induration,  but  it  gradually  shades  off 
into  the  adjacent  tissue  and  it  is  hard  to  tell  where  it  stops;  but 
the  induration  of  a  chancre  is  different,  its  boundary  line  is  well 
denned,  it  stops  abruptly  and  if  once  felf',  you  will  never  forget  it. 
It  resembles  the  feel  of  a  piece  of  parchment  in  the  superficial 
yariety  and  that  of  a  split  pea  in  the  deep  variety.  A  chancre  is 
charaterizcd  by  being  usually  single,  this  is  because  you  can't  have 
syphilis  but  once,  and  the  chancre  is  formed  at  the  point  of  inocu- 
lation; it  is  not  auto-inoculable;  that  is,  if  you  have  a  chancre  on 
the  penis,  you  can't  inoculate  yourself  from  it  on  other  portions 
of  the  body,  but  it  is  hetero-inocuable;  that  is,  it  can  inoculate 
other  people  and  a  chancre  tends  to  get  well  itself  without  treat- 
ment, in  from  six  weeks  to  two  months  if  it  is  kept  clean.  Chan- 
croid is  not  a  form  of  pox,  for  it  is  entirely  a  local  disease.  It 
sometimes  complicates  the  chancre  and  causes  it  to  be  obscure. 
A  chancroid  is  auto-inoculable  and  areuerally  plural  in  number. 
There  is  such  a  thing  as  a  mixed  chancre.  This  is  an  unfortunate 
term,  as  it  implies  a  cross  between  the  diseases,  but  it  means  the 
individual  has  both  diseases  in  the  same  manner  as  a  child  may 
have  whooping  cough  and  measles  at  the  same  time,  each  being 
separate  diseases.  In  the  primary  stage  we  also  have  the  develop- 
ment of  the  Syphilitic  Bubo,  which  is  an  enlargement  of  the 
nearest  lymphatic  gland   to   the   chancre.      It   may  form  in  any 


PRINCIPLES    OF    SURGERY.  183  • 

gland:  if  the  chancre  is  on  the  penis,  it  forms  in  the  groin;  if  the 
chancre  is  on  the  lip,  it  forms  in  the  glands  below  the  jaw,  etc. 
The  gland  commences  to  enlarge  as  the  chancre  develops,  remains 
as  long  as  the  chancre  remains  and  disappears  with  its  disappear- 
ance. The  sj^philitic  bubo  is  generally  oilateral,  polyglandular, 
hard,  movable  and  painless. 

SECONDARE  SYPHILIS.— The  chancre  of  the  priirary  stage 
has  healed,  the  buboes  have  become  smaller  or  disappeared,  and 
there  is  a  rescind  stage  or  the  second  period  of  incubation  is  on 
which  last  about  six  weeks.  The  patient  legins  to  think  the  doc- 
tor has  made  a  mistake,  his  future  gets  brighter  and  he  is  no  l3nger 
troubled.  At  the  expiration  of  the  sixth  week  other  nanifesta- 
tions  appear,  headache,  backache,  slight  fever,  anorexia  and  rest- 
lessness. These  symptoms  last  from  one  to  two  weeks  and  on 
arising  one  morning  he  finds  an  eruption  on  his  chest,  but  the 
above  symptoms  have  disappeared.  The  eruption  which  appears 
is  characterized  by  four  features.  I'irst,  Protean  type;  that  is,  it 
has  no  peculiar  type,  it  is  all  mixed  up,  macules,  papules  and 
\esicles.  Second,  The  eruption  is  symmetrical,  if  it  occurs  on  one 
arm  it  occurs  also  on  the  other.  Third,  When  it  begins  to  fade  it 
leaves  a  peculiar  dusky  red  copper  discoloration  of  the  skin. 
Fourth,  It  does  not  itch.  The  eruption  comes  on  suddenly  and 
fortunatelv  it  never  appears  on  the  face  or  hands  and  can  there- 
fore bt;  hidden  b}  the  clothing.  From  two  days  to  a  v^eek  sore 
throat  comes  on;  the  throat  is  congested  and  inllamed,  there  is 
difficulty  in  swallowing  and  there  is  hoarseness.  On  examination 
you  will  find  the  throat  ulcerated  on  the  upper  part  of  the  pharynx 
and  on  the  fauces.  Mucous  patches  now  develop.  This  is  a  most 
disgusting  symptom.  They  form  on  any  portion  of  the  body  ivhere 
the  skin  or  mucous  membrane  is  thin  and  subject  to  friction;  in  the 
mouth,  under  the  penis,  between  the  fingers,  in  the  folds  of  the 
neck,  rectum,  etc.  At  first  there  is  a  little  exudation  beneath  the 
skin  or  raucous  membrane,  which  looks  like  a  bursa;  this  enlarges, 
and  the  skin  becomes  a  dusky  red  or  copper  color,  it  then  disinte- 
grates, leaving  a  raw  surface  from  which  comes  a  nasty  discharge, 
which  coagulates  on  its  surface,  giving  the  patch  a  greenish  black 
appearance  and  emits  a  horrible  odor.  The  lymphatic  glands  soon 
become  enlarged  all  over  the  body.     Don't  confound  this  enlarge- 


184  PRINCIPLES    OF    SURGERY. 

ment  of  the  glands  wiih  buboes,  as  in  this  stage  all  the  glands  are 
enlarged  and  remain  so  throughout  life.  They  enlarge  slowly  and 
painlessly,  and  are  freely  movable.  Alopecia  or  loss  of  hair  is  a 
frequent  s3"mptom,  the  patient  becoming  bald  and  also  loses  his 
eyelashes.  The  eyes  and  ears  also  become  affected,  there  may  be 
iritis,  conjunctivitis,  etc.,  or  inflammation  of  the  tympanum  or 
middle  ear,  causing  great  pain,  and  the  disease  is  hard  to  manage. 
TERTIARY  SYPJIILIS.— The  above  symptoms  may  have  ex- 
tended over  a  period  of  twelvemonths,  but  with  "R.  S.  S."  and  other 
quack  remedies,  he  thinks  he  has  eradicated  the  disease.  A  rest 
comes  on,  but  after  this  the  third  period  of  incubation,  which  lasts 
a  variable  length  of  time,  the  tertiary  symptoms  appear.  This 
stage  of  the  disease  is  rarely  ever  reached,  but  if  it  does,  the  patient 
is  doomed,  there  is  no  cure  for  it.  It  is  not  syphilis,  but  the  effects 
of  syphilis.  It  is  not  contagious  and  can't  be  transmitted.  There 
are  depositions  of  gumraata  or  nodules  in  the  various  tissues,  com- 
posed of  granulation  tissue.  The  skin  is  seriously  affected.  There 
is  one  form  called  Tubercular  gummata,  which  forms  on  the  face, 
grows  to  about  two  inches  in  diameter,  undergoes  ulceration,  the 
cells  disintegrate,  the  nodule  breaks  down  and  a  large  ulcer  is 
formed,  eating  away  the  cheek  or  nose.  There  is  developed  some- 
times a  sqamous  trouble  of  the  arms  and  hands,  and  scales  fall 
from  the  parts  as  from  a  fish.  The  nails  become  twisted  and  dis- 
torted, constituting  Syphilitic  Onychia.  The  mucous  membranes 
are  also  affected.  Gummata  forms  on  the  tongue  and  destroys  the 
organ;  in  the  throat,  oesophagus,  colon,  rectum,  etc.  They  are 
painless,  ulcerate  and  are  har'd  to  heal,  and  if  you  do  heal  them, 
the  contraction  of  the  cicatrix  produces  stenosis,  and  the  patient 
"v^ill  be  unable  to  swallow  if  the  ulcer  is  seated  in  the  throat  or 
oesophagu^'.  If  it  is  in  the  rectum  or  colon,  the  patient  may  die 
before  the  surgeon  recognizes  the  trouble.  The  disease  may  in- 
volve the  solid  viscera,  as  the  heart,  lungs,  kidne3^s,  etc.  The 
ulceration,  of  these  organs  causing  death,  or  the  contraction  of  the 
cicatrix  so  impairing  the  organ  that  it  will  not  be  able  to  perform 
its  function.  Xervous  symptoms  supervene.  There  are  deposi- 
tions of  gummata  on  the  brain  and  spinal  cord,  these  by  contrac- 
tion impair  the  function  of  the  part,  causing  idiocy,  paralysis,  loco- 
motor ataxia,  epilepsy,  etc.     The  arterial   system  suffers,  and  the 


PRINCIPLES    OF    SURGERY.  185 

trouble  may  be  coEfounded  with  senile  degeneration  of  the  arteries, 
the  difference  being  that  the  latter  only  attacks  the  large  arteries, 
whilst  in  syphilis  the  small  arteries  are  affected.  In  the  senile 
trouble  the  arterial  "walls  become  calcareous  in  nature,  while  in 
syphilis  there  is  a  deposit  of  fibrous  tissue  and  the  contraction 
occludes  the  lumen  of  the  vessel.  Areolar  tissue  may  also  be  the 
seat  of  these  deposits,  which  ulcerates  and  burst  upon 
the  surface,  leaving  a  deep  ulcer.  Bones  and  periosteum  may  be 
attacked,  causing  periostitis,  osteitis  and  syphilitic  nodes  form  on 
the  subcutaneous  surfaces  of  the  tibia,  ulna,  radius  and  the  cra- 
nial bones. 


LECTURE  XLI, 


SYPHILIS— COXTIXUED. 

Hereditakt  Syphilis,  or  syphilis  due  to  disease  of  one  or  both 
parents,  is  characterized  by  there  being  eo  primary  stage  of  the 
chancre  and  bubo.  The  symptoms  commence  \^ith  the  secondary 
stage.  This  is  due  to  the  embryo  not  being  iroculated  locally,  the 
virus  being  carried  directly  into  the  blood.  Infantile  syphilis  is 
also  a  term  applied  to  hereditary  syphilis.  This  is  unfortunate,  as 
they  are  entirely  di^erent,  for  infantile  syphilis  may  be  hereditary 
or  acquired. 

Causes. — Hereditary  syphilis  may  be  caused  by  one  of  four 
conditions.  First.  By  the  mother  being  syphilitic,  the  father  being 
health3%  their  offspring  may  be  born  in  the  full  bloom  of  syphilis, 
but  it  is  usually  of  a  mild  type  uhich  is  readily  amenable  to  treat- 
ment. A  syphilitic  woman  will  give  birth  to  a  s\^phiiitic  child  long 
after  she  is  capable  of  infecting  her  husband.  Second.  The  mother 
and  father  both  being  syphilitic.  This  is  a  much  more  frequent 
cause  and  in  this  case  the  disease  in  the  offspring  is  very  virulent 
and  quickly  terminates  disastrously  unless  properly  treated. 
Third.   The  mother  acquiring  syphilis  after  impregnation.      Sup- 


186  PRINCIPLES    OF    SURGERY. 

pose  a  healthy  maa  and  woman  marry,  the  woman,  becomes  im- 
pregnated and  six  months  afterwards  the  husband  acquires  syphilis 
and  inoculates  his  wife;  the  child  was  begotten  ty  healthy  parents, 
but  the  effect  of  the  woman  acquiring  syphilis  is  thus  stated.  If 
the  mother  acquires  the  disease  before  the  seventh  month  of  preg- 
nancy, the  child  will  becoine  infected,  but  if  she  acquires  the  dis- 
ease after  the  seventh  month  the  child  will  be  born  healthy. 
Fourth.  The  father  inoculating  the  child,  without  infecting  the 
mother.  This  seems  improbable,  but  it  is  claimed  by  good 
authority  to  be  true,  while  others  equally  as  eminent  dispute  it. 

Results  to  the  Child  of  Having  a  Stphilitic  Mother  may  bo 
as  follows:  1.  Abortion  or  premature  birth.  The  products  of  the 
cohabitation  of  syphilis  is  usually  thrown  out  the  wound  before  the 
third  month.  If  you  have  a  woman  who  aborts  time  and  time 
again  at  or  near  the  third  month  of  pregnancy,  treat  her  for  syph- 
ilis, no  matter  what  she  says,  it  can't  do  any  harm,  and  as  a  gen- 
eral thing  does  good.  2,  Full  term  children  born  with  syphilitic 
lesions.  Suppose  an  abortion  does  not  occur  at  the  end  of  the 
third  month  and  the  woman  goes  to  full  term.  The  child  in  this 
case  will  be  born  in  the  full  bloom  of  syphilis,  or  else  be  born 
healthy  and  develop  the  disease  soon  afterwards  and  in  the  se- 
condary stage.  In  the  latter  event  the  symptoms  usually  develop 
in  two  or  three  weeks,  but  it  may  be  as  long  as  a  month  or  even  a 
year.  But  when  the  disease  doesn't  develop  in  a  year's  time,  you 
can  safely  say  that  the  child  is  out  of  danger.  If  the  disease  de- 
velops after  a  year's  time,  the  child  either  had  the  symptoms  of 
the  disease  during  the  first  year  and  was  overlooked  or  else  it  has 
acquired  the  disease  from  a  wet  nurse  or  by  kissing  a  syphilitic 
person. 

Symptoms. — The  general  appearance  of  the  child  is  striking.  It 
is  shrunken  and  shriveled,  eyes  glassy,  predernaturaliy  bright  and 
old  looking.  The  skin  is  usually  covered  with  an  eruption,  which 
is  protean  in  charactei,  distributed  syrametricaliy,  fades  away  and 
leaves  a  dusky  red  copper  discoloration  and  it  does  not  itch.  There 
are  mucous  patches  on  the  skin  and  mucous  membrane,  as  in  the 
mouth,  between  the  fingers  and  in  the  rectum.  The  throat  is  sore 
and  is  manifested  by  what  the  old  granny  calls  sniffles.  The  mu- 
cous membrane  of  thfi  nose  is  thickened,  and  he  is  unable  to  breathe 


PRINCIPLES    OF    SURGERY.  187 

through,  it,  consequently  he  can't  occlude  his  mouth  with  tbe  nip- 
ple to  nurse.  The  hair  falls  out  and  the  glands  all  over  the  body 
become  enlarged.  If  the  child  lives  and  the  period  of  priiiary 
dentition  comes  on,  the  teeth  will  be  diseased.  They  will  be  soft 
and  crumbly-,  and  as  soon  as  they  come  through  the  gums,  they 
are  broken  off  and  the  child  becomes  snaggled  toothed.  With 
these  symptoms  the  child  generally  dies  of  marasmus  despite  your 
treatment,  but  it  may  live  and  fight  along  and  appear  apparently 
cured.  Bui;  when  the  second  dentition  comes  on,  characteristic 
appearances  develop.  Linear  lines  radiate  from  the  mouth  to  the 
cheek,  eye  troubles  develop,  such  as  inflammation  of  the  cornea, 
opacity  of  the  cornea,  etc.  The  second  teeth  are  called  Hutchin- 
son's teeth.  The  incisor  teeth,  espucially  those  of  the  upper  jaw, 
being  wedge-shaped,  broad  -dl  the  gums  and  tapering  down.  They 
project  forward  and  are  notched;  that  is,  their  cutting  edge  in- 
stead of  being  straight  are  curved. 

SYPHILIS  IN  G-ENERAL -Diagnosis.— As  I  have  said  be- 
fore, this  disease  reposes  a  great  responsibility  on  the  doctor,  and 
an  early  and  careful  diagnosis  should  be  made,  as  it  influences  the 
w^hole  life  of  the  patient.  Never  deal  with  the  disease  lightly. 
If  you  find  out  that  your  patient  has  syphilis,  tell  him  so  at  once. 
The  diagnosis  is  largely  based  on  the  general  history.  If  the  dis- 
ease comes  under  your  observation  in  the  secondary  stage,  it  is 
easily  diagnosed,  but  if  the  disease  was  acquired  ten  years  before 
and  was  treated  at  the  time,  your  diagnosis  will  not  be  made  with 
such  ease.  They  seem  to  have  forgotten  all  about  having  the  dis- 
ease and  it  is  hard  to  obtain  their  correct  history.  You  can't  be- 
lieve a  word  the}''  tell  you,  even  though  otherwise  honest  and  reli- 
able. You  will  have  to  use  all  kinds  of  strategy  on  them  to  get 
the  truth.  If  a  man  comes  to  you,  and  although  he  may  be  a  low, 
degraded,  vile  fellow  and  is  abused  and  shunned  by  his  neighbors, 
and  you  find  a  Bot-e  on  his  penis  or  some  other  suspicious  place, 
dou't  treat  him  for  syphilis  until  you  make  a  positive  diagnosis; 
but  if  a  man  comes  to  you  who  is  looked  upon  as  a  saint  or  a  pillar 
of  a  church  and  can  pray  lou<ler  than  any  other  member  of  the 
congregation  and  shows  a  sore  in  a  suspicious  place,  don't  w^ait  for 
a  positive  diagnosis,  put  him  on  anti-syphilitic  remedies  at  once, 
as  these  remedies  will  cure  one  out  of  ten   such  cases.     Confron- 


188  PRINCIPLES    OF    SURGERY. 

tation  is  important  in  the  diagnosis  if  it  is  possible  to  do  so,  as  if 
the  women  has  a  chancre  she  has  given  the  man  a  chancre  and  if 
she  has  a  chancroid  she  has  given  him  a  chancroid.  Inoculation 
may  be  tried,  but  never  inoculate  any  one  else,  but  the  man  who 
has  the  suspected  chancre,  and  if  it  be  a  syphilitic  sore,  the  inocu- 
lation will  give  negative  results,  but  if  the  sore  be  a  chancroid,  a 
sore  will  develop  at  the  site  of  the  inoculation.  None  of  these 
tests  are  conclusive,  as  the  man  may  have  both  diseases.  It  is  im- 
possible to  make  a  positive  diagnosis  until  the  secondary  stage. 
Some  microscopists  claim  they  can  diagnose  the  disease  with  the 
microscope,  this  is  exceedingly  doubtful.  The  differential  diagno- 
sis between  a  chancre,  a  chancroid,  herpes,  cancer  and  tuberculosis 
belongs  to  another  department,  but  in  regard  to  the  difference  be- 
tween a  chancre  and  a  chancroid,  I  will  simply  give  you  a  few 
points  I  have  picked  up  in  practice.  A  chancre  has  a  definite 
period  of  incubation,  a  chancroid  has  not.  A  chancre  never  de- 
velops under  one  or  two  weeks,  a  chancroid  develops  in  one  or  two 
days.  A  chancre  is  always  single,  a  chancroid  is  always  multiple. 
A  chancre  is  not  auto-inoculabie,  a  chancroid  is.  A  chancre  is 
either  a  superficial  or  a  deep  Huriterian  sore;  if  superficial  there  is 
no  breach  in  the  continuity  of  the  skin  and  it  feels  like  a  piece  of 
parchment  beneath  the  skin;  if  it  is  a  deep  Hunterian  chancre  it 
has  sloping  margins  and  feels  like  a  split  pea;  a  chancroid  has 
sharply  punched  out  margins  and  is  migratory,  A  chancre  is  in- 
durated and  th3  hardness  is  sharply  defined  from  the  adjacent 
tissue,  stopping  ver;^  abruptly,  a  chancroid  is  also  slightly  indu- 
rated, but  the  hardness  gradually  slopes  off  into  the  adjacent  tissues. 
A  chancre  tends  to  heal  spontaneously,  a  chancroid  undergoes  pha- 
gedenic ulceration  and  spreads.  A  chancre  is  always  accompanied 
b}^  buboes,  which  are  bilateral,  polyglandular,  hard,  freely  mov- 
able and  do  not  tend  to  suppurate,  a  chancroid  is  not  usually  ac- 
companied by  buboes,  and  if  it  is,  the  bubo  is  unilateral,  involves 
only  one  gland,  it  is  immovable,  very  painful  and  tends  to  suppu- 
rate. A  chancre  is  always  accompanied  by  constitutional  symp- 
toms, a  chancroid  is  purely  local  and  is  never  accompanied  by  con- 
stitutional synr,  ptcms.  One  attack  of  syphilis  gives  immunity  to 
subsequent  attacks,  one  attack  of  chancroid  does  not  give  immu- 
nity to  subsequent  attacks. 


PRINCIPLES    OF    SURGERY.  189 

Pkognosis. — The  prognosis  of  syphilis  is  good.  I  have  already 
stated  that  in  forraer  years  the  disease  svas  very  malignant,  but  in 
recent  years  it  has  become  very  much  attenuated,  and  if  properly 
treated  it  doesn't  give  much  trouble.  If  a  man  comes  to  you  and 
you  suspect  syphilis,  give  him  a  bottle  of  colored  w  ater,  and  if  he  has 
syphilis  he  will  return  in  six  weeks  with  the  diagnostic  symptoms, 
then  if  you  treat  him  properly  the  symptoms  will  disappear  in  three 
weeks,  and  if  he  continues  the  treatment  he  will  be  entirely  cured 
and  will  live  to  an  old  age  and  die  from  some  other  trouble.  A 
great  many  observers  claim  that  Gonorrhoea  killo  more  people  than 
syphilis.  The  prognosis  is  based  on  the  type  of  the  chancre,  a  sa- 
perticial  chancre  is  milder  than  a  Hunterian  chancre;  on  the  char- 
acter of  the  eruption,  a  macular,  papular  eruption  gives  a  milder 
case  than  a  pustular  or  vesicular  eruption;  on  the  general  health, 
vigor  and  robustness  modifies  the  disease  and  on  the  length  of  the 
patient's  purse,  a  man  who  scuffles  for  a  living,  has  meals  irregular 
and  badly  cooked,  has  a  harder  time  than  a  man  who  can  afford  a 
French  cook. 

Syphilis  and  Maeeiage. — This  is  an  important  question  and  one 
that  will  be  propounded  to  you  frequently.  When  a  man  comes 
to  you  cvith  syphilis,  or  one  that  you  know  has  had  syphilis  a  year 
or  two  before  and  asks  you  the  advisability  of  his  getting  married, 
tell  him  he  will  have  to  postpone  it.  Some  authors  claim  that  a 
man  once  having  syphilis  is  never  free  from  it  and  should  not 
marry,  but  the  majority  of  authorities  and  observers  dispute  this 
and  claim  that  if  a  man  goes  Lhree  years  without  any  of  the  symp- 
toms of  the  disease  being  manifested,  he  can  marry  without  any 
fears  in  regard  to  the  future.  So  it  is  your  duty  as  a  doctor  to  see 
that  a  man  does  not  marry  until  three  years  has  elapsed  since  the 
last  symptoms  of  the  disease  disappeared. 


190  PRINCIPLES    OF    SURGERY. 


LECTURE  XLII. 


SYPHILIS— Continued. 

Tkeatment. — The  treatment  of  syphilis  is  divided  into  local, 
speciiic  and  general.  They  are  usually  carried  on  at  the  same 
time,  but  will  be  considered  separately. 

Local  Treatment. — This  is  the  treatment  applied  to  the  local 
lesions,  as  chancre,  bubo,  mucous  patch,  etc.,  and  to  prevent  de- 
formity and  pain.  It  must  always  be  re-enforced  by  the  specific 
and  general  treatment.  The  local  treatment  of  a  chancre  depends 
on  the  variety,  the  superficial  and  Hunter ian  variety  requiring 
different  treatment  to  the  phagedenic  type.  If  a  man  comes  to 
you  ivith  a  siiperficial  or  deep  chancre,  the  first  question  that 
arises  is  the  advisability  of  cutting  it  out.  On  this  question 
authorities  differ.  Some  claim  that  if  it  is  cut  out,  the  disease  will 
be  aborted,  or  if  symptoms  do  develop  they  v^ill  be  mild,  while 
other  equally  competent  observers  claim  that  to  excise  a  chancre 
does  no  good,  constitutional  symptoms  always  follow.  My  ex- 
perience makes  me  belive  that  it  is  unwise  to  excise  the  sore.  The 
disease  is  never  local,  it  is  constitutional  from  the  very  moment 
the  lesion  occurs  and  therefore  excision  can  do  no  good.  There  is 
on  record  a  case  of  a  man  that  came  to  the  doctor  six  hours  after 
having  connection  with  a  s3'^philitio  woman,  and  showed  an  abra- 
sion on  his  penis.  The  wound  was  immediately  cauterized,  but  in 
three  weeks  a  chancre  developed.  So,  as  a  general  rule,  let  the 
chancre  alone,  but  if  the  patient  says  he  must  continue  sexual  in- 
tercourse or  the  sore  is  on  some  portion  of  the  body  where  it  gives 
trouble,  excise  it  for  convenience  sake  and  not  for  the  abortive 
treatment.  If  you  want  to  note  the  difference  between  an  untreated 
and  a  treated  chancre,  get  two  patients  and  on  one  cauterize  the 
chancre  with  nitrate  of  silver  and  paint  it  with  a  dirty  salve;  leave 
the  other  one  alone,  and  the  untreated  chancre  will  get  well  first. 
A  patient  coming  to  you  will  demand  some  treatment,  so  prescribe 
the  yellow  or  black  wash,  tell  him  to  bathe  in  hot  water  night  and 
morning  and  apply  the  wash.      When  he  comes  again  ^y°q  him  a 


PRINCIPLES    OF    SURGERY,  191 

mild  antiseptic  powder  to  use,  such  as  iodoform  or  aristoL     The 
phagedenic  chancre  demands  prompt  and  heroic  measures  or  there 
will  be  disastrous  results.     Immediately  cauterize  the  chancre.     In 
using  a  cautery  in  genito-urinary  surgery  it  does  not  matter  what 
kind  vou  use,  but  your  ability  to  use  it.      I^ever  use  nitrate  of  sil- 
ver, it  is  a  delusion  and  a  snare,  it  is  no  good.     Use  Bromine,  red 
hot  iron   or  fuming   nitric   acid.      The  operation  can  be  rendered 
painless  v^ith  cocaine.      After  cauterizing,  treat  the  burn  with  an 
antiseptic  solution  and  dust  it  with  some  antiseptic  powder.      Syphi- 
litic buboes  should  be  let  alone,  as  they  do  no  harm,  are  painless 
and   tend  to   spontaneously   disappear.     If,  however,  the  mental 
condition   of  your  patient  demands  it,  paint  them  with   Iodine. 
Never   order   a   bottle  of   Iodine  and  a  camel's  hair  brush  and  let 
the   patient  apply    the  drug,  but  appl}^  it  yourself.      Paint   round 
each  gland  very  carefully,  as  if  you  thought  too  much  of  the  drug 
would  effect  disastrous  results.      If  he  comes  back  complaining  give 
a   prescription   for  mercurial  ointment  and  let  him  use  that  for  a 
while.     You  have  to  feed  them  on  bland  medicines,  which  really 
do  no  good,  but  to  give  nature  a  chance.      I  do  not  teach  you  this 
to  make  you  fakirs,  but  it  is  necessary  to  enable  you  to  hold  your 
patients  and  to  keep  them  out  of  the  hands  of  quacks.     Sore  throat 
should   be   treated  locally   with   gargles   or   sprays.     Chlorate  of 
potassium,  chloral,  thymol,  tincture  of  benzoin,  etc.,  may  be  used 
in   solutions.     If  the  throat  is  congested   and   contains   mucous 
patches,  give  him  a  spray  containing  a  small  amount  of  cocaine  in 
a  boracic  acid  solution.     Mucous  patches  should  be  wipea  off  with 
some  antiseptic  solution,  dried   with  a  blotter  and  cauterized  with 
Acid  Nitrate  of  Mercury,  after  this  apply  soixe  antiseptic  powder. 
Alopecia  deserves  treatment.      If  it  is  insignificant,  prescribe  the 
''''Seven  Sutherland  Sisters'  Hair  ToiiiG,^"'  but  if  it  is  rapidly  falling 
out,  leaving  patches  of  hair  here  and  there,  order  his  head  shaved, 
and  then  wash  it  night  and  morning  with  hot  water  and  green  soap 
and  apply  some  hair  tonic.      All  hair  tonics  contain  about  the  same 
ingredients  mixed  differently.     Quinine,  Pilocarpine,  Cantharides, 
Glycerine,  Castor  Oil  and  Bay  Rum.     Iritis  or  inflammation  of  the 
iris,  if  not  treated,  will  result  in  either  total  blindness  or  serious  im- 
pairment of  sight.    The  iris  may  even  become  glued  to  the  lens.    The 
treatment  consist  of  the  unsparing  use  of  atropia.     Make  a  solution, 


192  PRINCIPLES    OF   SURGERY. 

2  grains  to  the  onrce  of  \vater,  and  drop  two  or  three  minims  into 
the  eye  three  times  daily.  This  will  keep  the  pupil  dilated,  aad  if 
adhesions  fcrm,  the  pupil  being  in  this  dilated  condition,  the  sight 
can  be  restored  with  the  proper  glasses.  Use  antiseptic  solutions 
freely,  and  use  cocaine  for  the  pain.  A  good  mixture  to  meet  all 
of  the  above  requirements  can  t3e  ordered,  consisting  cf  Boracic 
acid,  Cocaine  and  Atropine  in  distilled  water.  Hot  water  applied 
to  the  eye  frequently  relieves  the  swelling  and  reduces  the  inflam- 
mation. Gummata  and  ulcers  which  form  in  the  tertiary  stage  do 
Eot  yield  readily  to  treatment.  You  can  try  a  salve,  but  they  are 
rapidly  being  done  away  with  in  surgery.  The  best  salve  is  a  mix- 
ture of  Calomel  3i  to  Vaseline  oi.  Don't  delude  yourself  by  adding 
carbolic  acid,  as  carbolic  acid  in  grease  is  inert.  If  this  does  no 
good,  use  a  collodion  composed  of  Bi-chloride  of  Mercury,  salicylic 
acid  and  collodion;  paint  this  over  the  ulcer.  It  not  oily  protects 
the  ulcer,  but  causes  the  tissue  it  is  composed  of  to  disintegrate. 
As  a  last  resort,  cut  out  the  diseased  tissue,  making  your  incision 
through  healthy  tissue  and  treat  as  a  recent  wound. 

Sj>eGiJic  Treatment. — This  consist  in  cither  the  administration  of 
Mercury  or  Iodine.  Mercury  is  an  antidote  for  syphilis,  it  neu- 
tralizes the  virus,  but  we  do  not  understand  its  action.  Some  ob- 
servers claim  that  it  is  decomposed  and  metallic  mercury  is  de- 
posited, which  goes  through  the  capillaries  and  pushes  the  syphilis 
out  the  back  door.  I  believe  it  is  due  to  the  antiseptic  properties 
of  mercury,  and  this  is  one  evidence  of  the  disease  being  of  micro- 
bic  nature.  "When  should  you  begin  mercury  and  when  must  you 
stop  it?  No  man  living  can  sa}"  positively  that  a  man  has  syphilis 
until  the  secondary  stage,  other  diseases  have  almost  the  same  set 
of  symptoms  as  syphilis  in  the  primary  stage,  and  therefore  never 
admioister  mercury  until  the  early  secondary  symptoms  appear. 
If  you  give  it  before  this  time,  it  is  possible  your  patient  hasn't 
the  disease,  or  you  may  so  mask  the  secondary  stage  that  six 
months  afterwards  he  appears  well  and  you  come  to  the  conclusion 
that  your  diagnosis  was  wrong  and  the  treatment  is  stopped ;  when 
the  disease  appears  again  it  is  in  the  full  bloom  of  tertiar}'-  syphilis 
and  your  patient  is  doomed.  So  when  a  patient  comes  to  you,  and 
you  suspect  syphilis,  dou't  give  him  mercury,  prescribe  some  bland 
colored   drug  a,nd  wait  until  he  comes  to  you  with  the   secondary 


PRINCIPLES    OF    SURGERY.  193 

syrnptoms  of  syphilis,  when  your  diagnosis  is  certain.  Then  give 
him  mercury  and  continue  it  for  a  year  as  continuously  as  possible. 
ISTovv  discontinue  the  drug  and  give  him  an  occasional  course  of 
the  drug  during  the  next  two  or  three  years.  The  preparations 
used  are  Calomel,  Blue  Mass,  Bi-chloride,  Biniodide,  Protoiodide, 
Ointment  and  Oleate.  The  drug  may  be  administered  by  the 
mouth,  inunction,  fumigation  or  hypodermically.  It  may  seem 
foolish  to  give  you  so  many  avenues  of  introducing  the  drug,  but 
when  you  have  a  patient  that  can't  take  the  drug  by  the  mouth, 
you  will  be  glad  to  know  of  other  ways  of  administration.  The 
mouth  is  the  most  satisfactory  avenue  of  introduction.  The  bi- 
chloride is  given  dissolved  in  some  bitter  tonic  as  Tine.  Gentian  or 
Cinchonae;  the  biniodide  is  used,  but  is  irritating;  the  protoiodide 
is  the  best  preparation,  being  less  irritating  and  put  up  in  conve- 
nient pill  forms  of  a  1-5  grain  each.  The  dose  of  the  protoiodide 
will  have  to  be  determined  for  each  patient.  Never  give  an  over- 
powering dose  and  salivate  your  patient,  but  go  about  it  systemati- 
cally. Give  one  pill  after  each  meal,  at  the  end  of  the  third  day 
give  two  after  breakfast  and  one  after  each  other  meal,  wait  three 
days  and  give  two  after  breakfast  and  dinner  and  one  after  sup- 
per, wait  three  days  and  give  two  after  each  meal  and  in  this  way 
gradually  increase  the  dose  every  third  day  until  the  patienl  comes 
to  you  with  colicy  pains  in  the  abdomen  and  his  teeth  feeling  too 
long,  then  you  may  know  you  have  almost  salivated  him.  Now 
divide  the  number  of  the  pills  in  half  and  you  have  the  dose:  that 
is,  if  he  is  taking  six  pills  a  day,  give  him  three  or  half  the  dose 
which  produces  physiological  symptoms.  If  the  patient  can't  take 
the  drug  by  the  mouth,  give  it  to  him  by  inunction.  For  this  pur- 
pose the  oleate  or  ointment  is  used,  the  20  per  cent,  oleate  is  the 
bes^,  but  is  very  expensive.  In  using  the  drug  by  inunction,  take 
a  piece  the  size  of  the  end  of  the  little  finger,  protect  your  hand 
with  a  glove  and  rub  the  drug  in  the  skin  where  it  is  thin,  as  on 
the  belly,  inner  side  of  thigh,  in  the  axilla,  etc.  Rub  it  in  a 
different  place  every  night  until  you  have  made  a  circuit  of  the 
body,  for  if  the  same  place  is  used  two  nights  consecutively,  it  will 
cause  irritation.  Some  authorities  recommend  the  drug  to  be 
smeared  on  a  band,  which  is  worn  around  the  belly  over  night; 
others  smear   the   drug  on   the   socks  and  friction  from  walking 

13 


194  PRINCIPLES    OF    SURGERY. 

causes  absorption.  If  a  patient  is  suffering  from  an  acute  lesion  of 
the  eye  or  brain  and  j^ou  wish  to  get  him  under  the  influence  of 
mercury  at  once,  adroinister  the  drug  by  fumigation.  Take  a  cane 
bottom  chair,  seat  the  patient  in  it  naked  and  enclose  him  in  a 
gossamer,  on!}'-  leaving  his  head  out.  Place  under  the  gossamer 
a  bucket  of  boiling  ^ater  to  open  the  pores  of  the  skin,  then  take 
20  grains  of  calomel,  place  it  in  a  tin  over  an  alcohol  lamp  and 
place  it  under  the  gossamer.  The  calomal  is  volatilized,  rises 
through  the  chair  and  is  deposited  on  the  body.  Let  him  remain 
in  the  fumes  for  twenty  minutes,  then  remove  the  bucket  of  water 
and  lamp,  and  let  him  remain  ten  minutes  longer,  when  he  should 
be  wrapped  in  a  dry  blanket  and  but  to  bed.  Give  him  a  bath 
the  next  aay.  Three  such  fumigations  will  cause  salivation,  but 
in  these  acute  lesions  never  dread  salivation,  your  object  is  to  get 
the  patient  under  the  influence  of  mercury  as  quick  as  possible. 
Sometinies  when  rapid  effects  are  desired,  the  hypodermic  use  of 
bi-chloride  is  used  in  1-16  to  -|^  grains  three  times  a  day.  Make 
the  injection  deep  dox^n  into  the  muscles,  or  else  irritation  follows 
with  the  formation  of  an  abscess.  JSIever  use  a  needle  over  two 
or  three  times,  as  the  mercury  makes  them  brittle  and  there  is 
danger  of  breaking  them  off  in  the  tissues.  Mercury  is  a  drug 
greatly  dreaded  by  the  public  on  account  of  its  abuse  in  the  past, 
but  if  given  carefully,  persistently  and  intelligently,  it  is  of  the 
greatest  value  in  the  treatment  of  syphilis.  It  sometimes  causes 
colicky  pains  and  diarrhoea,  for  these  give  large  doses  of  Sub-ni- 
trate of  Bismuth  and  change  the  preparation  or  mode  of  adminis- 
tration. Aphthous  stomatitis  may  occur,  if  so,  discontinue  the 
drug  for  a  while  and  use  antiseptic  mouth  washes.  Salivation  may 
occur.  The  patient  comes  to  you  and  says  his  teeth  are  too  long 
and  their  edges  sharp,  gums  tender  or  ulcerated  and  bleeds  easily, 
tongue  is  swollen  and  congested,  breath  fetid  and  saliva  is  constantly 
dribbling  from  his  mouth.  In  this  case  discontinue  the  mercury 
and  substitute  Iodide  of  Fotash.  Grive  a  mouth  wash  and  admin- 
ister internally,  the  following: 

R 

Potassii  Chloratis  ■    . ") 

Pulv.  Sulphur  a  a|  31 

M.  Ft.  cht.  No.  xii. 

Sig  : .   One  powder  four  times  a  day. 


PRINCIPLES    OF    SURGERY,  195 

Iodine  is  not  an  antidote  for  syphilis,  it  has  no  effect  on  syphilis, 
but  acts  entirely  on  the  products  of  syphilis.  It  is  not  used  or 
does  no  good  except  in  the  tertiary  stage.  It  causes  disintegration 
of  the  gummata  and  restores  the  tissues  to  their  normal  condition. 
Appreciating  the  above  facts,  never  give  Iodine  until  the  incipiency 
of  the  third  stage,  and  then  continue  the  drug  as  long  as  symptoms 
crop  out.  The  preparations  used  are  Tinct.  of  Iodine  (in  emer- 
gencies), Iodide  potash,  soda  and  ammonium.  Iodide  of  Potash 
is  the  most  popular  preparation.  The  drug  should  be  commenced 
with  small  doses  and  increased  steadily  to  the  point  of  tolerance. 
Order  a  saturated  solution,  commence  with  5  minims  after  meals 
and  gradually  increase  the  dose  until  40  or  60  minims  are  being 
taken  or  until  untoward  manifestations  are  noticed.  It  is  well  to 
know  that  in  a  saturated  solution  of  Iodide  of  Potash,  as  usually 
prescribed,  that  each  measured  minim  contains  1  grain  of  the  drug, 
but  each  drop  of  the  solution  does  not;  that  is,  when  the  medicine 
is  dropped  the  ounce  contains  960  drops  and  when  measured  only 
480  minims,  therefore  tell  your  patients  to  either  measure  the  dose 
or  double  the  number  of  drops  ordered,  when  the  medicine  is  sim- 
ply dropped  from  the  bottle.  The  evil  effects  of  the  Iodides  are 
coryza  and  skin  eruptions. 

General  Treatment.  —While  treating  the  disease  locally  aud 
fighting  the  virus  with  mercury,  don't  forget  the  general  treat- 
ment and  therefore  administer  tonics,  and  such  drugs  that  will 
assist  the  assimulation  and  digestion.  Stop  the  use  of  tobacco, 
chewing  causes  irritation  and  the  formation  of  raucous  patches. 
Smoking  also  favors  the  f9rn]ation  of  these  patches,  irritation  be- 
ing caused  by  the  pipe  stem  or  cigar.  Whiskey  must  be  withheld, 
as  syphilis  and  alcohol  give  bad  results,  but  in  an  old  man  who  is 
used  to  his  morning  dram,  let  him  have  it.  Care  should  be  taken 
vpith  the  diet,  a  liberal  supply  of  food  may  be  allowed,  but  it 
should  be  easy  of  digestion.  Plenty  of  outdoor  exercise  should  be 
advised.  Care  should  be  taken  in  regard  to  the  clothing;  flannel 
or  silk  should  be  worn  next  to  the  skin,  and  cotton  or  linen  pro- 
hibited, as  the  skin  is  depended  on  to  assist  in  the  elimination  of 
the  virus  and  mercury,  and  must  therefore  be  kept  warm.  A  hot 
bath  should  be  taken  three  times  a  week,  and  a  Turkish  bath  once 
a  week.     If  the  patient  is  full  of  malaria,    give  him  quinine;  if 


196  ■  •PRINCIPLES    OF    SURGERY. 

anemic,  give  Mm  iron;  if  tubercular,  give  him  cod  liver  oil.  If 
possible  send  your  patient  to  the  Hot  Springs.  I  have  served  as 
resident  physician  at  these  springs,  and  am  convinced  that  the 
medicinal  virtues  of  the  water  is  "?ii^."  The  benefit  derived  is 
not  from  the  water,  but  from  the  change  of  scenery,  rest  and  the 
regular  bathing.  In  town  a  man  is  worried  with  business  and  his 
family,  and  when  he  goes  to  the  springs  he  gets  mental  and  physi- 
cal rest.  The  baths  are  no  better  than  can  be  gotten  at  home  in 
the  bath  tub,  but  at  the  springs  they  are  taken  regularly  and  thus 
the  benefit. 


LKCTURK  XLIII. 


T[TMORS. 

The  term  Tumoe  is  often  used  indiscriminately  by  surgeons  to 
designate  all  kinds  of  swellings,  but  should  be  limited  in  its  appli- 
cation to  neoplasms  or  new  growth,  composed  of  tissue,  the  result 
of  proliferation  of  embryonal  cells  and  existing  as  a  more  or  less 
independent  structure  and  having  no  physiological  function.  For 
along  time  absurd  and  erroneous  ideas  of  the  nature  and  origin  of 
tumors  existed  in  the  minds,  both  of  the  laity  and  the  profession. 
Tumors  were  supposed  to  be  parasites  preying  on  the  system,  they 
were  thought  to  be  composed  of  material  essentially  different 
from  that  found  in  the  human  body,  and  in  some  instances  to  ha^e 
a  distinct  circulation  of  their  own,  Johannes  Muller  was  the  first 
to  teach  that  the  tissues  of  which  a  tumor  is  composed  always  has 
its  prototype  in  the  body;  Yirchow  dispelled  the  belief  that  a 
tumor  could  develop  ^'de  novo^''^  by  proving  that  it  always  had  ori- 
gin from  pre-existing  cells  of  a  similar  type,  and  Cohnheim  ad- 
vanced a  theory  to  explain  their  occurrence,  which,  though  incapa- 
ble of  being  demonstrated,  is  extrencely  plausible.  According  to 
Cohnheirn's  theory,  there  must  have  been  in  the  embryo  during 
its  development  more  cells  produced  at  some  point  than  was  neces- 


PRINCIPLES    OF    SURGERY.  197 

sary  for  the  formation  of  that  particular  region.  These  cells,  not 
utilized  by  the  growth  of  the  embryo,  were  arrested  in  their 
further  development,  and  remained  in  a  dormant  condition.  If 
their  activity  is  excited  later  they  proliferate  and  form  a  tumor. 
It  is  extremely  important,  before  going  farther,  to  draw  a  sharp 
line  of  distinction  between  tumors,  inflammatory  swellings  and 
retention  cysts.  All  true  tumors  are  composed  of  new  tissue,  pro- 
duced by  proliferation  of  embryonal  cells.  All  inflammatory  s  w  ell- 
ings  result  from  the  action  of  pathogenic  microbes  upon  mature 
tissue  cells.  All  retention  cysts  are  due  to  the  retention  in  a  pre- 
formed space  of  a  physiological  secretion  or  excretion. 

Classification'. — Until  the  publication  of  Yirchow's  paper,  in 
1863,  no  attempt  had  been  made  to  classify  tumors,  and  the  terms 
used  to  designate  the  different  varieties  were  based  upon  their  ap- 
pearance or  chief  characteristics,  such  as  scirrhus,  cauliflower, 
polyp,  fungus,  haematodes,  etc.  The  modern  classification  of 
tumors  is  based  either  upon  their  histological  structure  or  upon 
their  clinical  behavior.  Thus  tumors  are  said  to  be  Epiblastic, 
Mesoblastic  or  Hypoblastic,  as  their  structure  indicates  an  origin 
from  the  embryonal  cells  of  the  Epiblastic,  Mesoblastic  or  Hypo- 
blastic layers  of  the  foetus.  Tumors  are  said  to  be  Benign  or  Malig- 
nant, as  their  clinical  behavior  indicates  an  innoceot  or  a  vicious 
tendency.  Benign  tun,  ors  are  usually  homologous  or  composed  of 
tissues  resembling  those  in  which  it  originates,  have  a  distinct  cap- 
sule, are  freely  movable  beneath  the  skin,  are  poorly  supplied  with 
blood  vessels,  grow  slowly,  cause  little  pain,  do  not  infiltrate  ad- 
jacent tissue  or  involve  neighboring  glands,  and  when  completely 
removed  never  recur.  Malignant  tumars  are  heterologous  or  com- 
posed of  tissues  widely  differing  from  those  in  which  it  originates, 
has  no  capsule,  are  not  movable,  are  richly  supplied  with  blood 
vessels,  grow  rapidl}'',  cause  great  pain,  tend  to  infiltrate  adjacent 
tissue,  and  to  involve  neighboring  glands,  aad  frequently  recur 
after  radical  extirpation. 

Cause. — The  essential  cause  which  produces  a  tumor  is  the  exist- 
ence in  the  body  of  dormant  embryonal  cells.  The  exciting  causes 
which  produce  a  tumor  are  conditions  which  awaken  the  energies 
of  the  latent  cells,  and  inaugurate  their  proliferation.  A  combina- 
tion of  the  two  etiological  factors  is  necessary,  for  the  cells  of  the 


198  PRINCIPLES    OF    SURGERY. 

matrix  "would  remain  permanently  in  a  latent  condition,  unless 
stimulated,  while  all  intrinsic  and  external  exciting  causes  without 
a  matrix  upon  which  to  act  would  be  powerless  to  produce  a  tumor. 
Among  the  exciting  causes  may  be  mentioned  (aj  heredity,  a  ten- 
dency to  certain  forms  of  tumors  being  transmitted  from  parent  to 
offspring;  (b)  race,  the  negro  is  much  more  predisposed  to  Fibroids 
than  the  white  race:  (c)  climate,  the  inhabitants  of  tropical  regions 
being:  more  liable  to  malio-nant  troubles  than  those  who  dwell  in 
more  temperate  climates;  (d)  age,  puberty  and  senility  both  being 
periods  at  which  neoplasms  develop;  (e)  sex,  men  apparently  be- 
ing more  frequently  the  victim  than  women;  (f)  occupation,  the 
refined  and  cultivated  are  afflicted  with  tumors  more  frequently 
than  the  laboring  class;  (g)  traumatism,  such  as  a  fracture  some- 
times excites  the  formation  of  a  tumor;  (h)  irritation,  such  as  a 
jagged  tooth,  or  the  hot  stem  of  a  pipe  produces  cancer;  (i)  inflam- 
mation is  often  followed  by  tumoL"  production;  (j)  contagion  is  a 
doubtful  factor. 

rATHOLOGT. — (1)  Structure;  all  tumors,  whether  epiblastic,  me- 
soblastic,  hypoblastic,  benign  or  malignant,  are  composed  of  a 
parenchyma  and  a  stroma  of  fibrous  tissue,  the  same  as  an  ordinary 
gland.  In  sonje  instances  the  parenchyma  or  the  essential  cells,  are 
in  excess  of  the  strorca  and  the  tumor  is  soft,  again  the  stroma  is 
in  excess  of  the  pareu'^hyma  and  the  tumor  is  hard.  (2)  Shape; 
the  shape  aepends  entirely  on  accidental  cicuinstances,  the  tumor 
always  growing  in  the  direction  of  least  resistance.  They  may  be 
o'val,  smooth,  round,  noduJated,  broad,  fiat  or  pedunculated.  A 
sessile  tumor  is  one  which  grows  on  a  broad,  flat  surface;  a  pedun- 
culated tumor  is  constricted  at  its  base;  an  oval  tumor  is  one  that 
is  expanded  in  all  directions.  Their  surface  may  be  smooth,  lobu- 
lated  or  nodular.  (3)  Density;  some  are  hard  and  are  then  com- 
posed mostly  of  stroma;  some  are  soft,  and  are  composed  mostly 
of  parenchyma.  Some  are  compressible  and  are  then  very  vascu- 
lar, and  pressure  causes  compression  by  driving  the  blood  out; 
others  fluctuate  when  pressure  is  made  unequally  on  it,  this  is  due 
to  the  fluid  it  contains.  (4)  Color;  this  depends  upon  the  tissue 
producing  the  tumor,  it  is  red  in  myomata  or  muscle  tumor  and 
white  in  a  tumor  of  the  connective  tissue;  if  vascular,  they  are 
bright  red  in  arterial  and  blue  in  venom  tumors;  if  they  undergo 


PRINCIPLES    OP    SURGERY.  199 

fatty  degeneration  their  color  changes  to  yellow.  (5)  Growth; 
the  rapiditf  of  their  growth  depenils  upon  the  ceils  from  which 
they  are  formed,  connective  tissue  cells  growiag  much  faster  than 
nerve  cells,  and  upon  their  vascularity,  the  greater  their  blood  sup- 
ply the  more  rapid  their  growth.  (6)  Morbid  changes;  these  are 
identical  with  those  in  similar  normal  tissue.  They  may  undergo 
inflammation,  suppuration,  etc.,  due  to  microbic  infection.  Ilemor- 
rtiage  may  occur  from  rupture  of  a  blood  vessel.  (7)  Degenerative 
changes;  these  degenerative  changes  are  the  same  which  occur  in 
the  liver,  kidney,  etc.  They  may  uadergo  fatty,  mucoid,  amyloid, 
hyaline,  caseous,  calcareous  or  osseous  degeneration. 

Diagnosis.  —The  diagnosis  is  based  on  the  clinical  history  and 
on  a  careful  physical  examiuation  by  palpation,  percussion  and 
auscultation,  and  lastly  by  making  aa  exploratory  incision,  obtain- 
ing a  piece  of  the  tissue  ana  examining  it  under  the  microscope'-. 

Prognosis. — The  prognosis  depends  upon  the  type  of  the  tumor; 
it  is  good  in  the  benign,  but  bad  in  the  malignant  type.  Upon 
the  anatomical  location,  if  easily  removed  it  is  better  than  if  it  is 
not  accessible  to  the  surgeon's  knife,  and  lastly  it  depends  on  the 
general  health  of  the  patient. 

Treatment.  — Medical. — There  is  not «  single  case  on  record  where 
a  true  tumor  has  been  benefited  by  either  external  or  internal  admin- 
istration of  arugs,  but  if  the  swelling  be  from  inflammation  or  syph- 
ilis, it  will  be  benefited,  therefore  if  arsenic  or  mercury  lessens  the 
size  of  a  tumor,  you  have  made  a  mistake  in  your  diagnosis.  The 
only  applicatioa  of  medicines  in  tumors,  are  tonics  to  build  up  the 
general  health.  Sargioal. — This  consist  of  the  radical  extirpation 
of  the  growth,  cleanly  and  completely.  Some  tumors  are  so  situ- 
ated as  to  give  do  pain  or  discomfort  and  can  be  let  alone;  others 
do  not  endanger  life,  but  must  be  removed  on  account  of  the  dis- 
figurement the  cause.  Remove  all  tumors  if  possible  with  the 
knife,  always  cutting  through  healthy  tissue,  but  if  this  is  impos- 
sible use  the  thermo-cautery,  constriction  or  escharotics. 

Palliative.  —Thi^  is  the  treatment  applied  to  malignant  tumors, 
which  are  either  not  accessible  to  the  surgeon's  knife  or  have  passed 
the  pale  of  surgery.  The  treatment  consist  of  good  food,  tonics, 
stimulants  and  anodynes.  If  you  have  a  patient  ^^it)l  a  carcinoma, 
and  you  know   at  the  best  he  can't  live  very  long,  make  him  an 


200  PRINCIPLES    OF    SURGERY. 

habitual  opium  eater,  and  so  mate  him  live  the  rest  of  his  life  in 
peace  and  comfort.  Commence  with  small  doses  and  increase  the 
dose  gradually  until  he  can  take  as  much  as  8  grains  a  day.  JSTever 
start  to  using  the  hypodermic  syringe,  as  he  will  \Morry  you  to 
death  sending  for  you  to  give  bim  an  injection.  Don't  give  the 
opium  in  pills  or  camphor,  as  it  will  soon  upset  the  stomach,  but 
write  for  the  following : 

R 

Morphine  Sulph.  grs  viii 

Ess.  Pepsin  (Fairchild's)  §iv 

M.  Sig :  As  indicated. 


LECTURE  XLIV. 


BENIGlSr  TUMORS. 

Fibromata  or  fibrous  tumors  are  composed  of  fibrous  tissue. 
On  section,  they  are  smooth,  firm,  glistening  and  of  a  grayish 
white  colcr.  Tbey  occur  wherever  fibrous  tissue  is  found  in  any 
of  its  forms,  but  tbe  most  frequent  seat  is  the  periosteum.  Fibro- 
mata are  oval,  hard,  nodulated  and  of  uniform  consistency;  they 
grow  slowly,  give  little  pain  and  are  freely  movable.  They  should 
be  removed  as  soon  as  discovered,  and  if  enucleation  is  complete, 
there  is  no  danger  of  recurrence. 

LiPOMATA  or  fatty  tumors  are  composed  of  adipose  tissue  identi- 
cal with  normal  fat.  They  have  a  thin  capsule,  wbich  is  attached 
by  fibrous  septa  to  adjacent  tissue.  They  are  found  commonly  on 
the  shoulders,  back  and  buttocks.  Lipomata  are  circumscribed, 
painless,  soft,  inelastic  mass.  They  grow  slowly,  but  sometimes 
attain  considerable  size.  If  the  edge  is  pressed  upon  by  the  finger 
it  slips  away.  They  should  be  treated  by  making  a  free  incision, 
and  shelling  the  tumor  out  of  its  capsule. 

Chonbkomata  or  cartilagenous  tumors  are  composed  of  some 
variety  of  cartilage.     On  section  they  are  homogenous,  translucent 


PRINCIPLES    OF    SURGERY.  201 

and  pinkish  ^ray  in  color.  They  are  usually  composed  of  hyaline 
or  iibrc -cartilage.  They  occur  commonly  near  the  epiphysis  of 
the  long  bones,  and  are  sometimes  seen  in  the  testicles  and  parotid 
gland.  Chondromata  are  hard,  elastic,  slowly  enlarging  growths, 
often  nodular  or  lobulated  and  give  little  pam.  Their  treatment 
consist  in  the  complete  removal  x^ith  the  knife  and  periosteal  lifter. 

OsTEOMATA  or  osseous  tumors  are  composed  of  true  bone,  and 
are  generally  formed  entirely  of  either  cancellous  or  compact  tis- 
sue. Tne  cancellous  tx^pe  is  usually  found  near  the  epiphysis  of 
long  bones,  and  may  result  from  ossification  of  a  chondromata. 
The  compact  type  is  usually  found  projecting  from  one  of  the  cra- 
nial bones,  and  often  is  of  an  ivory  hardness,  and  exceeding  diffi- 
cult to  cut  away.  Osteomata  are  always  connected  with  bone, 
and  are  hard  and  immovable.  They  are  either  pedunculated  or 
have  irregular  nodular  surfaces.  They  should  ouly  be  removed 
T\hen  they  give  rise  to  pain  or  are  steadily  growing. 

Odontomata  or  tooth  tumors  are  composed  of  a  mixture  of  den- 
tine, enamel  and  cementum.  They  occur  in  the  deial  arch,  and 
are  the  result  of  the  '^misdirected  energy  of  a  tooth  germ."'''  Odon- 
tomata  are  dense  in  structure,  irregular  in  shape  and  rarely  exceed 
a  normal  tooth  in  size.  They  may  project  through  the  gum  along 
with  the  teeth,  or  they  may  remaia  embedded  in  the  substance  of 
the  alveolus.  When  diagnosed,  they  should  be  removed  with  for- 
ceps or  chiseled  out  with  bone  instruments. 

Myxomata  or  mucous  tumors  are  composed  of  jelly  resembling 
the  vitreous  humor  of  the  eye.  They  are  soft,  gelatinous,  semi- 
translucent  and  enveloped  in  a  capsule.  They  occur  commonly  in 
the  nasal  cavity  and  are  sometimes  seen  in  the  mammary  gland, 
intermuscular  spaces  and  sub-mucous  and  sub  seroas  surfaces. 
They  grow  slowly  and  may  reach  a  large  size.  They  should  be 
lemoved  when  practicable. 

Myomata  or  muscular  tumors  are  composed  of  muscle  tissue. 
Rarely  these  growths  are  forrued  of  striated  cells;  com^monly  they 
are  composed  of  the  non-striated  variety.  They  occur  frequently 
in  the  uterus  and  prostrate  gland.  Myomata  are  firrr ,  sometimes 
smooth,  but  more  often  nodular,  and  on  being  cut  presents  an  ap- 
pearance closely  resembling  a  fibromata.  Tiie  tumor  is  intrinsically 
innoceut,  but  sometimes  mechanically  interferes  with  the  function 
of  an  organ,  and  then  demands  removal. 


202  PRINCIPLES    OF    SURaERY. 

Papillomata  or  "s\arty  tumors  are  composed  of  epithelial  and 
connective  tissue,  and  resemble  in  structure  hyper trophied  papilla 
of  the  skin  or  raucous  membrane.  They  occur  most  frequently  on 
the  hands  and  genital  organs,  owing  to  the  exposure  of  these  re- 
gions to  dirt  and  irritation.  Papillomata  may  appear  as  small 
cauliflower  masses,  or  as  flattened  elevations,  or  as  villous  tumors. 
These  growths,  while  innocent,  often  degenerate  into  epitheliomata, 
and  hence  should,  be  removed,  by  either  the  knife  or  caustics. 

AxGEioMATA  or  blood  vessel  tumors  are  composed  of  newly 
formed  and  old  dilated  blood  vessels.  They  form  swellings  of 
different  shapes  aud  sizes,  all  characterized  however,  by  being 
bright  or  dark  red  in  color,  soft  and  compressible  in  consistency. 

The  treatment  of  angeiomata  consists  ia  their  extirpation  \\ith 
the  knife,  ecrasseur  or  themo-cautery. 

Ltphangeiomata  or  lymph  vessels  tumors  correspond  to  the 
angeiomata  of  the  blood  vessels,  and  consist  essentially  of  dilated 
and  hypertrophied  lymph  vessels.  The  tumors  sorcetiraes  reach  a 
considerable  size,  and  are  filled  with  a  fluid  which  usually  is  clear, 
but  sometimes  miity.  The  treatment  consists  of  excision  and 
when  this  is  considered  hazardous,  the  growth  may  be  destroyed 
by  splitting  it  open,  and  packing  with  iodoforn  gauze. 

jS'edromata  or  nerve  tumors  are  composed  essentially  of  new 
formed  nerve  fibre.  It  is  necessary  to  draw  a  distinction  between 
true  and  false  neuromata.  A  false  neuromata  consists  in  a  growth 
of  fibrous  or  muscular  tissue  on  a  nerve  trunk  or  terminal,  which 
displaces  or  destroys  its  fibre;  as  an  example,  may  be  cited  the 
so-called  amputation  neuromata.  The  true  neuromata  consist  of 
newly  formed  nerve  fibres.  Neuromata  are  innocent  growths,  but 
often  cause  great  pain.  The  treatment  consists  in  e;stirpation, 
and  if  this  necessitated  the  division  of  a  nerve  trunt,  the  subse- 
quent restitution  of  continuity  by  a  plastic  operation. 

Lymphomata  or  tumors  of  lym.pbatic  glands  arise  from  pre  exist- 
ing lymphatic  glands,  and  are  usually  seen  on  the  neck  or  in  the 
axilla.  They  are  disfiguring,  and  while,  innocent  in  nature,  may 
cause  danger  mechanically.  They  should  be  removed  by  free  dis- 
section. 

Adenomata  or  glandular  tumors  are  composed  of  acinous  or 
tubular  glandular   tissue  mixed   with  connective  tissue  in  varying 


PRINCIPLES    OF    SURGERY.  203 

proportions.  Adenomata  are  innocent  growths  and  give  little 
pain.  The  acinous  variety  occurs  in  the  mammary,  ovary,  tests 
and  other  glands.  The  tubular  in  the  intestines;  especially  the 
rectum.     The  treatment  consists  in  early  excision. 

CysToiMATA  or  C3"stic  tumors  are  growths  whose  walls  are  pro- 
duced from  a  matrix  of  embryonal  cells,  and  whose  contents  are 
the  products  of  the  cells  lining  the  cyst  wall.  This  definition  re- 
stricts the  term  cystomata  to  neoplasms  or  new  growths,  and  does 
not  include  the  class  of  swellings  due  to  the  retention  in  a  pre- 
formed space  of  physiological  secretions  or  excretions  from  the  ob- 
struction to  the  outlet  of  a  gland.  The  w^all  of  a  cystomata  is 
formed  by  proliferation  of  cells,  and  the  contents  of  the  cyst  is  a 
substance  produced  by  the  cells  of  the  cyst  wall.  A  cystomata 
grows  rapidly,  and  ma^v  cause  considerable  pain.  Its  density  de- 
pends upon  the  tension  tc  which  the  wall  is  subjected  by  its  con- 
tents. It  may  be  soft  and  fluctuating,  it  may  be  so  firm  as  to  im- 
part the  sensation  of  solidity.  Their  most  frequent  seat  is  the 
neck  and  abdominal  region.  Cystomata  are  benign  growths,  but 
cause  trouble  from  pressure.  They  should  be  early  and  completely 
removed. 

Teratomata  are  tumors  composed  of  tissues  which  do  not  nor- 
mally exist  at  the  place  where  the  tumor  grows.  The  highest 
type  of  a  Teratomata  is  where  an  organ  or  set  of  organs  develop. 

The  simpler  variety  is  composed  of  heterogeneous  tissue,  such  as 
bone,  teeth,  hair  and  skin.  Teratomata  are  usually  located  in  the 
ovary,  but  they  may  develop  at  almost  any  partoP  the  tody.  It  is 
impossible  to  make  a  diagnosis  until  an  exploratory  incision  is 
made.     They  should  be  removed. 


204  PRINCIPLES    OF    SURGERY. 


LECTURE  XLV. 


MALIGNANT  TUMORS. 

Sarcomata.  A  sarcomata  is  a  malignant  tumor  composed  of 
embryonal  connective  tissue,  and  may  exist  wherever  normal  con- 
nective tissue  is  found.  Their  characteristics  are  those  of  all  malig- 
nant neoplasm;  it  is  not  encapsulated,  are  plentifully  supplied 
"with  blood,  grows  rapidly,  causes  great  pain,  infiltrates  adjacent 
tissue,  and  when  removed  they  tend  to  recur. 

Structure. — A  sarcomata  is  formed  of  connective  tissue  cells  em- 
bedded in  a  homogeneous  matrix.  It  has  no  stroma  or  connective 
tissue  trabeculae,  but  is  held  together  by  an  amalgam  or  cement 
substance  which  binds  the  cells  together  and  separates  one  from 
the  otiher.  The  solidity  of  the  tumor  depends  on  the  amount  of  the 
cement  substance.  (A  carcinomata  has  trabeculae  and  fascia  to 
hold  the  cells  together  but  has  no  intercellular  cement  substance.) 
A  sarcomata  contains  a  bountiful  supply  of  blood  vessels,  which 
run  between  the  cells  in  the  cement  substance.  Their  walls  are 
thin  and  imperfect,  sometimes  only  consisting  of  a  mere  channel  in 
tbe  cement  substance.     Sarcomata  contain  no  lymphatics. 

Varieties.  There  are  three  varieties,  the  difference  being  based 
on  the  variety  of  cells  they  contain. 

(1)  Round  cell  Sarcomata. — This  tumor  is  composed  of  round 
cells,  the  result  of  the  proliferation  of  embryonal  connective  tissue 
cells.  The}'"  are  about  the  size  of  a  white  blood  corpuscle,  con- 
tains one  or  two  nuclei  and  are  held  together  by  a  intercellular 
cement  substance  forming  a  fluctuating  mass.  This  is  a  rapidly 
growing  tumor  and  is  very  malignant.  Their  most  frequent  site 
is  in  the  periosteum  of  bones,  buc  are  also  found  in  fascia,  sub- 
mucous tissue,  mammary  gland,  ovary,  &c. 

(2)  Spindle  cell  sarcomata. — This  is  a  little  higher  type,  the  con- 
nective tissue  cells  being  more  mature.  It  is  formed  of  spindle 
shaped  connective  tissue  cells,  resembling  very  much  bearded  oats, 
with  sprangled  ends.  They  are  laid  side  by  side  their  ends  inter- 
lacing and  are  bound  together  bv  a  sticky  gelatinous  cement  sub- 


PRINCIPLES    OF    SURGERY.  205 

stance  which  is  leiss  in  proportion  than  found  in  the  round  cell 
variety,  and  the  tumor  is  therefore  harder  and  denser  than  the  first 
variety.  They  are  found  in  the  mammary  gland,  ov^ary,  uterus, 
testes,  and  sometimes  in  the  prostate  gland. 

(3)  Giant  cell  s^rccmaz!^.-— This  variety  is  not  formed  entirely  of 
giant  cells,  but  a  mixtare  of  round  cells,  spindle  cells  and  giant 
cells,  but  receives  the  name  of  the  most  characteristic  type,  which 
is  the  giant  cells.  These  cells  are  a  hundred  times  as  large  as  a 
white  blood  corpuscle,  contains  granular  protoplasm,  and  has  about 
fifteen  to  twenty  nuclei  which  are  arranged  around  the  periphery 
of  the  cells.  The  cells  are  bound  together  by  an  intercellular 
cement  substance.  They  are  only  met  with  in  bones,  the  most 
common  seat  being  the  medullary  canity.  They  grow  slowlv, 
causes  considerable  pain,  and  can  be  diagnosed  by  the  bulging  of 
the  bone. 

Pathology.  Row  do  these  cumors  grow,  start  and  progress? 
They  begin  to  grow  the  moment  the  ilet  of  deposit  of  dormant  em- 
bryonal cells  are  stimulated,  which  causes  the  cells  to  proliferate. 
The  c»^l)s  rapidly  divide  but  none  of  them  ever  reach  maturity. 
They  do  not  push  the  cells  in  which  they  grow  aside,  as  in  a  benign 
tumor,  but  infiltrates  and  penetrates  them.  Then  there  is  a  grad- 
ual dissemination  of  the  growth  and  colonies  form  on  different  por 
tions  of  the  body.  This  is  accomplished  by  some  few  of  the  sar- 
comatous cells  entering  a  vein  and  are  carried  to  every  portion  of 
the  body  and  form  new  growths.  There  is  no  dissemination  through 
the  lymphatics,  as  these  tumors  contain  no  lymph  vessels,  but  are 
bountifully  supplied  with  bloodvessels.  These  tumors  on  account 
of  their  rapid  formation,  poor  development,  are  liable  to  degenera- 
tive changes;  such  as  fibrous,  osseous  or  calcareous  degeneration. 

Symptoms. — These  vary  with  the  variety  of  the  sarcomata  and 
the  location.  There  is  in  all  the  types  pain,  swelling  and  de- 
formity. If  the  tumor  is  seated  in  the  liver,  its  function  is  inter- 
fered with;  if  in  the  brain,  there  is  imbecility,  &c. 

Diagnosis. — The  diagnosis  depends,  1st,  on  the  age  of  the 
patient;  sarcomata  rarely  forming  after  the  35th  or  iOth  year. 
2nd,  on  its  consistency,  there  are  usually  cystic  cavities  in  the  in- 
terior which  makes  it  unequally  hard  to  the  touch.  3d,  They  are 
differentiated  from  a  benign  tumor  by  the  fact  that  they  develop 


206  PRINCIPLES    OF    SURGERY. 

rapidly;  and  frcm  the carcinomata  by  not  involving  the  neighbor- 
ino;  D-lands. 

Pjrognosis  — The  prognosis  depends  on  the  type;  the  round  cell 
sarcomata  is  more  malignant  than  a  spindle  cell  sarcomata,  and 
the  spindle  cell  sarcoirata  is  more  malignant  than  the  giant  cell 
sarcomata.  It  also  depends  on  the  anatomical  location  of  the 
tumor;  if  it  is  in  brain  or  stomach  the  prognosis  is  grave,  but  i^  it 
is  situated  on  the  periosteum,  hand  or  foot,  where  it  is  accessible 
to  the  surgeon's  knife,  the  prognosis  is  better. 

Tkeatment. — The  treatment  consist  in  the  immediate  and  abso- 
lute removal  of  the  growth.  It  a  man  comes  to  you  with  a  sar- 
comata on  his  hand,  and  it  is  yet  in  its  incipiency,  cut  off  the  arm; 
if  on  his  foot,  cutoff  leg;  if  on  the  breast  of  a  woman,  extirpate  the 
gland,  and  if  it  is  on  the  uterus,  perform  a  hysterectomy.  If  the 
patient  does  not  come  under  your  care  until  general  dissemination 
has  occurred,  don't  operate,  it  is  too  late.  Although  eminent  sur- 
geons claim  that  the  Toxins  of  the  germ  of  Erysipelas  does  not  affect 
sarcomata;  you  can  try  them  on  the  hopeless  cases  as  a  last  resort. 

Cargijs-omata  or  Cancer. — This  is  a  malignant  neoplasm  or 
tumor  formed  from  embryonal  epithelial  cells,  and  having  clam- 
like prolongations  extending  from  its  margins  into  the  adjacent 
healthy  tissue.  It  has  all  of  the  characteristics  of  a  malignant 
tumor;  it  has  no  capsule,  has  a  bountiful  blood  supply,  grows 
rapidly,  causes  great  pain,  infiltrates  adjacent  tissue,  involves 
neishborino-  s'lands  arid  tends  to  recur  when  removed. 

Structdrb. — It  is  composed  essentially  of  epithelial  cells  held 
together  by  trabeculae  or  stroma.  It  contains  no  intercellular 
cement  substance  and  is  held  together  only  by  the  trabeculae  or 
stroma.  The  stroma  is  composed  of  connective  tissue  which  in- 
tersects and  divides  the  growth  into  small  apartments.  Each 
apartment  is  filled  with  epithelial  cells,  which  are  so  concentrically 
arrang:}d  that  they  are  said  to  have  a  nest-like  appearance.  The 
tumor  is  richly  supplied  with  blood  vessels  and  lymphatics  and  as 
they  pass  by  each  apartment  oE  cells,  a  cwig  is  given  off  to  them. 

Pathology. — A  carcinomata  or  cancer  begins  in  individuals 
who  have  formed  in  embryonal  life,  more  epithelial  cells  than 
were  necessary  to  build  up  the  foetus.  These  superflous  cells  lay 
dormant  until  stimulated,    when  they  divide  rapidly,  each  beget- 


PRINCIPLES    OF    SURGERY.  207 

ting  a  child  after  its  own  kind  and  a  tumor  is  formed.  These  cells 
do  not  })ush  aside  the  adjacent  tissue,  but  permcjates  and  infiltrates 
it.  Cancer  like  a  sarcomata  tends  to  form  colonies  in  various  por- 
tions of  the  bod}'-,  but  the  disease  is  not  disseminated  through  the 
blood  vessels  as  in  sarcomata,  but  by  the  lymphatics.  When  the 
disease  commences  to  disseminate  the  lymphatics  and  also  their 
glands  become  hard,  gland  after  gland  is  conquered  until  the  gen- 
eral lymph  circulation  is  reached;  the  diseased  cells  then  pass 
through  the  heart  and  is  disseminated  through  the  body,  when 
general  infection  occurs. 

Varieties. — There  are  two  broad  classes;  Epithelial  cell  carci- 
mata  and  Spheroidal  cell  carcinomata.  Epithelial  cells  occur  nor- 
mally! either  as  a  squamous  or  a  columnar,  and  cancerous 
growths  always  possess  one  of  these  types  of  cells.  Tney  are 
squamous  cells  when  they  come  from  the  skin,  and  spheroidal 
when  they  come  from  a  gland,  and  this  being  the  case,  the  micro- 
scope will  tell  you  where  the  cells  came  from.  (1)  Epithelial  cell 
carcinomata.- — This  type  is  composed  of  squamous  epithelial  cells, 
held  together  and  di\^ided  o(f  into  apartments  by  a  stroma  of  con- 
nective tissue.  It  develops  usually  at  the  junction  of  the  skin 
and  mucous  membrane;  as  on  the  alae  of  the  nose,  corner  of  the  eye, 
lips,  penis,  &c.,  but  it  also  occurs  in  other  localities,  but  more 
frequently  in  the  places  named  above.  (2)  Spheroidal  cell  carci- 
nomata or  columnar  cell  carcinomata  is  that  variety  of  cancer 
which  forms  in  glands  and  whose  cells  are  spheroidal  or  columnar 
shaped  and  divided  off  into  apartments,  and  held  together  by  a 
stroma  of  connective  tissue.  They  occur  in  the  mammary  gland, 
ovary,  uterus,  liver,  pancreas,  kidney,  spleen,  testes,  and  some- 
times in  the  prostate  gland. 

Symptoms- — The  sjnriptoms  depend  on  the  location  of  the  tumor. 
There  is  always  pain  and  deformity  and  the  other  symptoms  depend 
on  the  anatomical  seat  of  the  disease.  Besides  the  local  syrap 
toras.  there  are  general  symptoms  spoken  of  as  Cancerous  cachexia. 
The  patient  has  a  peculiar  appearance,  which  consist  of  a  pale  white 
hue  of  the  skin.  It  is  not  like  the  appearance  of  a  malarial  or  anemic 
person,  but  the  skin  is  drawn,  eyes  sunken  and  gives  the  appear- 
ance of  a  being  drawn  downward.  There  is  also  anemia  and  loss 
of  strength  and  tissue,  which  is  not  only  due  to  pain,  but  also  to 
the  absorption  of  the  specific  toxins. 


208  PRINCIPLES    OF    SURGERY. 

Diagnosis.  —The  diagnosis  is  based  oa  the  age,  carcinomata 
rarely  occur  under  fort}'"  years  of  age;  on  the  tumor  sending  out 
prolongations  into  the  adjacent  tissue,  and  it  is  diagnosed  from 
sarcomata  by  the  lymphatic  glands  being  involved. 

Prognosis. — The  prognosis  depends  on  the  variety,  the  epithelial 
cell  carcinomata  being  more  easily  eradicated  than  the  spheroidal; 
upon  the  seat  of  the  tumor,  if  on  the  nose  or  lip,  or  any  place  of 
easy  access  to  the  surgeon's  knife,  the  prognosis  is  better  than  if 
it  is  seated  in  the  uterus  or  liver.  ISTo  matter  how  often  and  how 
completely  removed,  this  class  of  tumor  always  tends  to  recur. 
Statistics  show  that  after  complete  excision,  75  per  cent,  oi  the 
operations  are  not  permanently  successful.  The  important  point 
is  to  remove  the  tumor  before  glandular  enlargement  has  taken 
place,  with  general  dissemination. 

Treatment. — ^Extirpate  the  tumor  as  early  as  possible.  Remove 
the  organ  involved  if  possible,  and  if  accessible,  remove  the  dis- 
eased lymphatic  glands.  You  must  operate  in  all  cases  of  cancer, 
not  with  the  view  of  curing  the  patient,  but  it  always  does  good 
by  stopping  the  pain,  life  is  prolonged  and  hope  restored. 


LECTURE    XLVI. 


RETENTIOiSr  CYSTS. 

A  Rerention  Cyst  is  an  enlargement  due  to  the  retention  of  a 
normal  secretion  or  excretion  in  a  performed  space,  the  retention 
being  caused  by  the  obstruction  of  the  duct  by  which  the  secre- 
tions or  excretions  normally  escape.  For  example:  one  of  the 
ureters  may  become  obstruccted,  and  a  retention  cyst  will  form  in 
the  pelvis  of  the  kidney  or  even  in  the  substance  of  the  gland 
itself.  The  term  Retention  cyst  is  vaguely  used  and  is  often  con- 
founded with  Cystomata;  but  a  cystomata  is  a  tumor  formed  from 
the  proliferation  of  embryonal  cells,  the  cyst  wall  and  contents 
are  freshly  built;  whereas  in  a  retention  cyst,  the  walls  pre-existed 


PRINCIPLES    OF    SURGERY.  209 

and  the  only  abnormality  is  the  obstruction  of  the  duct  with  con- 
saquent  retention  of  normal  excretions  or  secretions. 

Stkucture. — It  consists  of  a  cyst  wall  and  cyst  contents.  The 
iwall  is  the  duct  or  the  gland  itself;  for  instance,  if  the  obstruction 
is  at  the  hilura  of  the  kidney,  the  kidney  and  its  capsule  would 
form  the  C3^st  wall;  but  if  the  obstruction  Avas  in  the  ureter  near 
the  bladder,  the  wall  of  the  ureter  would  form  the  cyst  wall. 
"When  a  cyst  commences  to  grow,  its  walls  are  thick,  but  from 
pressure  they  beccme  as  thin  as  paper  or  the  wall  may  be  thin, 
and  from  irritation  becomes  thickened.  The  walls  of  a  cyst  are 
gradually  reduced  to  sin  pie  connective  tissue,  the  glandular  tissue 
being  absorbed.  The  cyst  contents  consists  primarily  of  the 
secretions  or  excretions  of  the  gland  in  which  it  is  formed,  but 
as  the  cyst  grows,  various  changes  occur  which  so  alters  its  ap- 
pearance that  it  will  not  be  recognized  as  a  normal  fluid;  inflamma- 
tion and  supjmration  may  occur,  when  it  will  be  mixed  with  pus 
or  some  tlood  vessel  will  rupture  and  pour  its  contents  into  the 
cyst  and  so  disguise  its  contents. 

Causes. — The  causes  are  numerous,  but  the  most  frequent  are 
inflammation  or  some  mechanical  obstruction.  For  instance, 
some  large  gland  secreting  from  one  to  twenty  pints  a  day  through 
a  fine  capillary  duct  which  becomes  obstructed;  on  examination 
you  \shl  find  the  adjacent  tissues  inflamed,  causing  obstruction  to 
the  duct  or  it  is  being  pressed  on  by  a  tumor. 

"Varieties. — Retention  cysts  may  occur  in  almost  any  portion 
of  the  body,  but  the  following  situations  are  the  more  frequent 
sites.  (1)  Skin;  they  occur  on  the  skin  in  one  or  two  types, 
Sebaceous  or  Sudoriferous  cyst  depending  upon  whether  the  duct 
of  a  sebaceous  or  sweat  gland  is  obstructed.  Sebaceous  cyst  are 
usually  situated  on  the  scalp,  but  may  occur  on  any  portion  of 
the  body.  When  incised  they  shell  out  readily.  The  treatment 
consist  of  rendering  the  part  aseptic,  incising  the  lump,  grasp  the 
sack  with  forceps  and  shell  it  out;  stop  the  bleeding,  take  one  or 
two  stitches  and  dress  the  woucd.  Sometimes  inflammation  has 
occurred  causing  adhesion  to  form,  and  the  sack  will  have  to  be 
dissected  out,  for  if  it  remains  the  cyst  vfill  recur.  (2)  Mucous 
membrane;  retention  cysts  sometimes  form  on  mucous  membranes. 
There  are  in  all  mucous  surfaces,  mucous  crypts  whose  functions  is  to 

14 


210  PRINCIPLES    OF    SURGERY. 

secrete  mucous  which  lubricates  the  surface.  If  the  mouth  of 
these  crypts  become  occluded  a  retention  cyst  forms.  The  treat- 
ment consist  of  a  free  incisioo  and  the  removal  of  the  capsule. 
Kern  ember  in  the  treatment  of  all  cyst,  that  it  does  no  good  to 
incise  the  enlargement  and  allow  the  capsule  to  remain;  and  if 
you  find  the  capsule  so  adherent  as  to  be  impossible  to  be  dis- 
sected out,  destroy  it  by  curetting  and  packing  with  iodoform 
gauze,  which  should  remain  until  the  pressure  has  destroyed  the 
capsule.  (3)  Fallopian  tubes;  these  tubes  are  open  at  both  ex- 
tremities, and  if  one  or  both  ends  become  occluded  a  retention 
cyst  forms.  The  usual  cause  is  gonorrhea,  but  it  may  be  pro- 
duced by  a  more  innocent  cause.  If  the  contents  of  the  cyst  is 
composed  mostly  of  water,  it  is  called  Hydrosalpinx,  and  if  it 
contains  pus,  it  is  called  Pyosalpinx.  The  fallopian  tube,  though 
normally  very  small,  is  distended  until  it  looks  like  a  saucer. 
(4)  Appendix:  the  openicg  into  the  appendix,  situated  at  its 
junction  with  the  caecum,  sometimes  becomes  occluded,  mucus 
accumulates  and  suppuration  may  occur,  but  the  trouble  was 
originally  a  retention  cj^st.  (5)  Ovary:  a  graafian  follicle  reach- 
ing maturity  fails  to  rupture,  its  secretions  and  excretions  can't 
escape,  distention  occurs  and  the  follicle  is  transformed  into  a 
retention  cyst,  which  may  reach  an  enormous  size.  (6)  Testicles: 
there  is  a  possibility  of  the  duct  of  these  giacds  becoming  occluded, 
with  consequent  accumulation  of  its  secretions  and  a  retention 
cyst  is  formed.  (7)  Gall  tract:  the  gall  duct,  common  duct  or 
cystic  duct,  from  inflammation,  pressure  of  a  tumor  or  impaction 
of  a  calculus,  will  cause  the  bile  to  be  retained,  and  althougli  some 
of  it  will  be  reabsorbed,  a  retention  cyst  forms.  (8)  Kidney  the 
ureters  may  become  obstructed  by  a  calculus,  inflammation,  pres- 
sure of  a  tumor,  or  by  the  ligature  of  a  careless  surgeon,  and  the 
urine  being  unable  to  escape  is  retained,  constituting  a  disease 
known  as  Hydronephrosis.  The  cyst  may  contain  a  gallon  cf 
urine.  These  cysts  are  also  sometimes  seen  in  the  Pancreas, 
Thyroid  gland.  Mammary  and  Salivary  giacds,  due  to  obstruction 
of  their  ducts. 

Symptoms. — The  first  sj'^mptom  is  swelling  or  increase  in  bulk, 
which  is  also  common  to  hypertrophy  and  other  troubles.  The 
general  symptoms  depend  on    the  organ  involved;  if  it  is  in  the 


PRINCIPLES    OP    SURGERY.  211 

salivary  gland,  the  symptoms  are  practically  "nil,"  but  if  it  is  in 
the  gall  tract,  there  will  be  jaundice,  profuse  vomiting,  &c.,  and 
if  in  the  kidney,  there  will  be  pain,  tenderness,  scant  urine  and 
swelling. 

DiAGKosis.  —The  diagnosis  is  based  on  the  clinical  history,  care- 
ful physical  examination  by  palption,  percussion  and  auscultation 
and  can  be  confirmed  by  the  aspirator. 

Peognosis. — The  prognosis  is  based  on  the  organ  involved  ,  and 
on  the  complications.  A  sebaceous  cyst  amounts  to  nothing,  but 
if  it  is  a  cyst  of  the  kidney,  the  prognosis  is  bad,  especially  when 
core  plicated  by  suppuration  with  a  low  grade  of  septicenia  or 
Pyaem  ia . 

Tkeatment. — The  proper  treatment,  if  it  is  possible  to  do  so,  is 
to  remove  the  obstruction.  If  there  is  a  cyst  of  the  gall  bladder 
due  to  pressure  from  a  tumor,  remove  the  tumor,  or  if  in  the 
kidn^,  due  to  the  obstruction  of  the  ureter  by  a  calculus,  remove 
/the  calculus.  Jf  you  can't  remove  the  obstruction,  the  neat  best 
treatment,  is  to  make  an  artificial  fistula.  For  instance:  if  there 
is  obstruction  to  the  urethrae  and  you  can't  remove  the  otstruc- 
tion,  make  an  artificial  urethrae;  if  he  is  suffering  from  Hydro- 
nephrosis, make  an  artificial  fistula,  and  the  rest  given  the  ducts 
by  these  fistula,  frequently  return  them  to  their  normal  condition. 
If  you  find  none  of  the  above  pracitcable,  excise  the  whole  busi- 
ness; if  it  is  a  sebaceous  cyst,  remove  the  whole  gland;  if  it  is 
Hydronephrosis,  remove  the  kidney. 


212  PRINCIPLES    OF    SURGERY. 


LECTURE  XLVII. 


ASEPTIC  AND  ANTISEPTIC  SURGERY. 

ITS    ORGANIZATION    AND    DETAILS    OF    PREPARATION. 

Reparation  of  the  patient. — The  patient  should  be  under  ob- 
servation for  some  days  before  the  operation,  and,  if  possible,  con- 
fined to  bed  for  the  last  da}'  or  two,  thus  allowing  the  various  or- 
gans to  accustom  themselves  to  the  new  conditions  in  \^hich  they 
will  be  placed.  The  function  of  the  skin,  kidneys  and  bov\  els  should 
be  stimulated,  if  sluggish  from  improper  habits  of  living,  the 
heart  carefully  examined  to  determine  the  safety  of  the  anaesthetic, 
and  the  urine  analyzed  to  ascertain  the  condition  of  the  oigans 
T^hich  excrete  it.  A  warm  plange  bath  should  be  given  daily,  and 
also  an  antiseptic  vaginal  douche,  if  the  patient  be  a  woman.  The 
diet  should  be  simple  and  nutritious,  and  of  a  character  to  leave 
little  residual  matter  in  the  intestines.  The  bowels  should  be  evac- 
uated daily,  and  a  purgative  given  the  night  before  the  operation, 
followed  by  a  simple  enema  the  next  morning.  A  large  dose  of 
quinine  should  be  given,  as  clinical  experience  has  shown  that  its 
influence  lessens  surgical  shock. 

The  morning  of  the  operation  a  general  bath  should  be  given 
with  warm  water  and  soap,  and  the  part  to  be  operated  upon 
cleanly  shaved.  The  area  should  be  well  scrubbed  with  hot 
water  and  green  soap,  washed  with  alcohol,  then  with  a  1:1000 
solution  of  bichloride  of  mercury,  and  finally  a  dressing  of 
bichloride  gauze  applied,  and  retained  in  place  b}^  a  bandage  or 
binder.  The  patient  should  be  dressed  in  a  fresh  suit  of  merino 
under  clothing,  woollen  socks  or  stockings,  a  night-gown,  and  a 
warm  wrapper. 

Ko  food  should  be  given  some  hours  before  taking  the  anaes- 
thetic, and  immediately  before  the  operation  the  bladder  should 
be  emptied. 

Preparation  of  Operating  Room. — Nothing  need  be  said  under 
this  head  With  reference  to  hospital  work,  as  all  connected  with 
these  institutions  are  thoroughly  familiar  with  the  details. 


PRINCIPLES    OF    SURGKRY.  213 

Nearly  all  large  hospitals  have  an.  operating  room  specially  ar- 
ranged for  surgical  work,  and  patients  are  taken  to  this  room, 
operated  upon,  and  then  carried  back  to  their  beds  in  the  private 
rooms  or  wards  of  the  buildings.  In  operating  in  a  private  house, 
however,  it  will  be  found  easier  to  operate  in  the  room  in  w  hich 
the  patient  is  to  be  placed  during  convalescence,  as  it  entails  less 
inconvenience  in  the  household,  and  lessens  the  work  of  prepa- 
ration. 

The  room  selected  should  be  moderately  large,  well-lighted, 
and  easily  ventilated  and  heated.  The  carpet  should  be  taken 
up,  and  the  curtains,  pictures  and  unnecessary  furniture  removed. 

The  wails  should  be  brushed  down,  and  the  floor,  frames  of  the 
doors  aiid  windows,  and  wood-work  of  the  furniture  washed  with 
1:1000  solution  of  bichloride  of  mercury. 

The  furniture  should  consist  onlv  of  a  bed,  two  chairs,  an  ope- 
rating table,  and  four  small  tables. 

The  bed  should  be  a  single  one,  preferably  of  iron,  and  should 
have  a  good  spring  and  a  firm  hair  mattress.  It  should  be  placed 
so  as  to  be  accessible  from  both  sides  and  the  foot. 

The  chairs  should  be  stiff  ones,  not  rockers,  and  of  wood,  so 
they  can  be  washed  without  injury. 

The  operating  table  should  be  firm  and  of  a  suitable  size  and 
shape.  A  pine  table,  such  as  is  commonh^  found  in  the  kitchen, 
or  two  small  tables  placed  end  to  end,  will  answer.  The  ope- 
rating table  should  be  placed  opposite  the  window  which  admits 
the  best  light,  and  the  lower  panes  of  the  ^^indow  screened  by 
tacking  a  piece  of  muslin  or  a  towel  across  them.  On  the  table 
should  be  placed  a  folded  blanket  and  a  pillow,  and  over  these  a 
rubber  protective  and  a  sterilized  sheet. 

The  four  small  tables  should  be  covered  with  sterilized  sheets  or 
towels.  One  should  be  placed  at  some  distance  from  the  operating 
table,  and  contain  the  basins  and  solution  used  in  sterilizing  the 
hands.  One  to  the  right  of  the  first  assistant  for  the  sponge 
basins,  one  to  the  light  of  the  operator  for  the  instruments  and 
aessings.  and  one  behind  the  operator  for  the  basin  of  pure  water 
in  which  to  wash  his  hands  during  the  operation. 

Akeangemexts  of  the  Patient. — It  is  important  to  prevent  the 
patient  being  chilled  during  the  operation,   as  it  increases  shook 


214  PRINCIPLES    OF    SURGERY. 

and  retards  reaction.  Care  should  be  raken  to  keep  the  tempera- 
ture of  the  room  uniforn],  to  a^cid  draughts,  to  make  no  unneces- 
sary exposure  of  the  body,  and  to  prevent  \^etting. 

If  the  site  of  the  operation  permits,  the  patient's  limbs  should 
be  closely  wrapped  in  a  blanket,  and  the  chest  protected  by  a 
folded  piece  of  flannel.  Hot  water  bags  may  be  placed  at  the 
patient's  feet.  The  limbs  should  be  secured  fcy  passing  a  band- 
age over  them  just  above  the  knees,  and  tying  tightly  under  the 
table.  The  arms  should  be  confined  to  the  sides  by  twisting  one 
end  cf  a  sterilized  towel  around  the  hand  and  wrist  and  thrusting 
the  other  end  under  the  patient's  hip.  Rubber  pads  or  sheets 
should  be  adjusted  so  as  to  prevent  the  various  solutions  employed 
from  saturating  the  patient's  clothing  and  bedding.  The  protec- 
tive dressing  should  be  then  removed  from  the  seat  of  operation, 
and  the  surface  again  washed  successively  with  alcohol,  1:1000 
solution  of  bichloride  of  mercury  and  sterilized  water.  The 
part  should  be  covered  with  a  large  piece  of  aseptic  gauze  having 
a  slit  cut  in  it  large  enough  through  which  to  work. 

Pkepaeation  of  Operator  atsd  Assistants.  — Before  beginning  a 
serious  operation,  the  operator  and  his  assistants  should  take  a 
full  bath,  and  put  on  an  entirely  fresh  suit  of  clothiag.  Their 
heads  should  be  protected  by  linen  caps,  and  their  bodies  by  linen 
gowns  or  sheet  aprons.  Their  arms  should  be  bare  to  the  elbow 
and  their  hands  carefull}''  sterilized. 

Duties  of  Assistants. — As  delays  in  an  operation  are  not  only 
annoying  to  the  surgeon,  but  dangerous  to  the  patient,  ic  is  impor- 
tant for  assistants  to  be  well  drilled,  and  to  know  exactly  what 
they  are  expected  to  do. 

The  number  of  assistants  and  their  duties  varies  with  different 
operators,  and  with  the  same  operator  under  different  circum- 
stances.    The  following  is  a  convenient  division  of  the  work: 

The  Anct^sihetizer  stands  at  the  headof  the  table.  His  duty  con- 
sists solely  in  the  administration  of  the  antesthetic,  which  requires 
his  individual  attention. 

The  Fir^t  Assistant  stands  on  the  left  side  of  the  table  oppo- 
site the  surgeon.  He  sponges  the  wound,  catches  bleeding  ves- 
sels, and  assists  the  operator  in  every  way  possible.  He  should 
endeavor  to  anticipate  the  needs  of  the  surgeon,  and  direct  the 


PRINCIPLES    OF    SURGERY.  215 

other  assistants  in  their  work,  thus  saving  the  operator  time  and 
trouble. 

The  Instrument  Assistant  stands  to  the  right  of  the  surgeon 
at  the  side  of  the  table  which  contains  the  instruments  and  dress- 
ings. He  hands  instruments  to  the  operator,  supplies  the  first 
assistant  with  ligatures,  and  threads  needles  with  the  required 
material,  as  they  are  needed.  As  soon  as  an  instrument  has  been 
used,  he  washes  it  in  sterilized  water,  and  returns  it  to  its  place 
in  the  trays. 

He  should  keep  an  accurate  list  of  the  instruments  in  solution, 
to  be  certain  that  none  are  lost.  It  is  also  his  duty  to  cut  the 
dressings  in  the  desired  shape,  and  if  their  application  devolves 
on  the  firat  assistant,  to  assist  him,  taking  the  place  at  the  side 
of  the  operating  table  vacated  by  the  surgeon. 

The  Sponge  Nurse  stands  behind  and  to  the  right  of  the  first 
assistant,  at  the  side  of  the  table  on  which  are  placed  the  basins 
for  the  sponges.  The  basins  should  be  two  in  number,  one  con- 
xaining  cold,  and  the  other  warm  sterilized  water.  The  first  as- 
sistant, after  using  a  sponge,  throws  it  into  the  basin  of  cold 
"v^ater,  the  nurse  frees  it  thoroughly  from  blood,  and  places  it  in 
the  basin  of  warm  water,  from  which  she  takes  it,  squeezes  it 
dry,  and  hands  it  to  the  first  assistant  when  needed. 

Sponges  should  be  washed  first  in  cold  water,  because  it  does 
not  coagulate  the  fibrin  of  the  blood,  and'  thus  prevent  its  re- 
moval. They  should  then  be  placed  in  warm  water  to  elevate 
theii  temperature,  and  to  prevent  their  chilling  the  tissues  to 
which  they  are  applied,  and  lowering  their  vitality. 

The  nurse  should  make  a  written  record  of  the  number  of  sponges 
in  her  charge;  and  if  this  number  is  increased  during  the  opera- 
tion, either  by  the  addition  of  new  sponges  or  by  the  division  of 
one  already  in  use,  the  record  should  be  corrected.  At  the  close 
of  the  operation,  she  should  count  the  sponges  aloud,  thus  as- 
suriQg  the  surgeon  that  none  have  been  left  in  the  wound  or 
abdominal  cavity. 

Extra  Assistant.  —The  assistants  just  named  are  not  allowed  to 
touch  anything  which  has  not  been  sterilized — hence  it  is  neces- 
sary to  have  an  extra  assistant  to  alter  the  position  of  the  patient 
on  the   table,   to   assist  the  antesthetizer  if  the  patient  vomits,  to 


216  PRINCIPLES    OF    SURGERY. 

empty  and  refill  basins,  to  open  and  close  the  windows  and 
doois,  and  todothe  many  little  things  which,  if  done  by  one  of  the 
other  assistants,  would  necessitate  the  re-sterilization  of  their 
hands  and  thus  delay  the  operation. 

After-Caee  of  the  Patient. — Unless  complications  occur,  the 
management  of  the  patient  after  an  operation  is  simple.  After 
the  patient  is  put  in  bed,  a  nurse  should  remain  at  the  bedside 
until  the  effects  of  the  anaasthetic  wear  off.  If  there  is  much 
shock,  it  should  be  combatted  ty  appropriate  remedies.  ]!^ausea 
is  usually  a  troublesome  symptom,  but  should  be  created  tenta- 
tively. Anything  m  the  stomach  aggravates  the  trouble,  and 
hence  little  or  no  vvater  should  be  given.  A  cloth  wrung  out  of 
ice-cold  water  placed  on  the  forehead,  or  a  mustard  plaster  on 
the  abdomen,  does  good.  The  dressmgs  should  be  frequently 
examined  to  see  if  there  is  any  indication  of  secondar}?^  hemor- 
rhage. Food  at  first  should  be  given  sparingly.  It  should  be  of 
a  liquid  form,  concentrated,  nutritious,  and  easily  digested.  The 
bowels  should  be  moved  on  the  second  day.  Unless  drainage  has 
been  used,  the  dressings  should  not  be  disturbed  for  a  week  or 
ten  days.  The  three  indications  for  changing  the  dressings  at  an 
earlier  date  are:  Pain,  fever,  and  saturation  of  the  dressings  with 
secretions  from  the  wound.  In  dressing  a  wound,  the  same  care 
should  be  exercised  to  prevent  its  infection  as  was  originally  ob- 
served at  the  time  of  the  operation. 

Pkeparation  of  Water. — An  abundance  of  both  hot  and  cold 
water  for  irrigating  the  wound  and  cleansing  the  hands,  instru- 
ments, and  sponges,  is  essential  in  an  operation.  Water  should 
be  free  from  both  inorganic  and  organic  matter,  as  the  presence 
of  inorganic  matter  acts  as  a  mechanical  irritant,  and  the  exist- 
ence of  organic  matter  vitiates  asepsis  by  the  introduction  of 
bacteria.  The  inorganic,  or  mineral  constituents,  can  be  removed 
by  either  distillation  or  filtration,  and  the  organic,  or  bacterial 
element,  by  boiling.  The  method  of  purifying  water,  therefore, 
embraces  two  processes — 

1st.  The  water  should  be  filtered  or  distilled, 

2d.  It  should  be  boiled  in  a  clean  vessel  for  at  least  ten 
minutes. 

A  portion  of  the  water  sbould  be  allowed  to  cool,  so  that  during 
the  operation  the  temperature  of  the  hot  water  can  be  lowered  by 


PRINCIPLES    OF    SURGERY.  217 

adding  cold  water  to  it.  JSTurses  sometimes  cool  water  by  putting 
in  a  lump  of  ice,  under  the  mistaken  impression  that  the  freezing 
process  has  destroyed  all  germ-life,  and  that  hence  the  water  re- 
sulting from  the  melting  ice  is  sterile.  Tt  is  as  important  for  the 
cold  water  to  have  been  boiled  as  it  is  for  the  hot, and  hot  steril- 
ized water  should  never  be  cooled  by  the  addition  of  cold  water 
which  has  not  been  so  treated.  If  sufficient  time  is  not  available 
to  allow  the  water  to  cool,  the  process  may  be  hastened  by  sur- 
rounding the  receptacle  with  ice,  but  the  ice  should  not  come  in 
actual  contact  with  the  water. 

Peepaeation  of  Solutions. — Solutions  are  used  as  disinfectants 
and  to  irrigate  and  clean  wounds  and  cavities.  The  folio  (ving  are 
the  methods  of  preparing  those  most  commonly  in  use. 

Pure  Water  is  prepared  by  filtering  or  distilling  water,  then 
boiling  for  ten  minutes,  and  allowing  it  to  cool  to  the  desired  tem- 
perature. 

Normal  Salt  Solution  is  prepared  by  adding  a  drachm  and  a 
half  of  chloride  of  sodium,  sterilized  by  heat,  to  two  pints  of  pure 
water,  filtering  through  filter  paper,  boiling,  and  allowing  it  to 
cool. 

TliiersoK' s  Solution  is  prepared  by  dissolving  two  parts  of  sali- 
cylic acid  and  twelve  parts  bcracic  acid  in  one  thousand  parts  of 
water,  filtering,  boiling,  and  allowing  to  cool. 

Bichloride  Solution  is  prepared  by  dissolving  in  a  given  quan- 
tity of  distilled  water  the  number  of  tablets  of  bichloride  of  mer- 
cury that  are  specified  on  the  bottle  by  the  manufcturer  to  make 
the  requisite  strength. 

Carh'oliG  Solution  is  prepared  by  adding  carbolic  acid  to  water. 
The  strength  usually  used  is  3  per  cent.,  and  the  solution  can  ap- 
proximately be  made  by  adding  four  drachms  of  carbolic  acid 
to  one  pint  of  sterilized  water. 

Hands. — The  hands  of  the  operator  and  assistants  are  the  most 
frequent  source  of  wound  infection — hence,  great  care  should  be 
taken  in  their  sterilization. 

In  sterilizing  the  hands,  the  arms  should  be  bare  to  the  elbow, 
the  skin  free  from  abrasions,  the  finger-nails  closely  trimmed  aod 
well  cleaned,  ard  rings,  if  worn,  removed. 

The  following  is  an  effective  process: 


218  PRINCIPLES    OF    SURGERY. 

1st.  Wash  the  hands  with  warm  water  and  green  soap,  to  re- 
move dirt.  A  nail-brush  should  be  vigorously  used,  to  render  the 
process  thorough,  and  special  attention  devoted  to  the  finger-nails 
and  tissues  around  them. 

2d.  Einse  all  trace  of  soap  from  the  hands,  aad  immerse  them 
in    absolute  alcohol  for  one  minute. 

3d.  Soak  them  for  the  same  length  of  time  in  a  warm  1:1000 
solution  of  bichloride  of  mercury. 

4:th.  Final!}'',  wash  them  in  one  or  two  sterilized  waters,  to  re- 
move the  bichloride,  and  dry  them  on  an  aseptic  towel. 

It  is  as  important  for  the  hands  of  an  assistant,  who  handles 
sponges,  instruments,  or  dressings,  to  be  as  clean  as  the  opera- 
tor's, and  they  should  receive  the  same  careful  attention.  If, 
during  the  course  of  an  operation,  the  surgeon,  or  an  assistant, 
touches  any  object  which  is  not  aseptic,  his  hands  should  be 
scrubbed  and  disinfected  anew. 

Instruments. — Instruments  should  be  simple  in  construction, 
and  readily  taken  apart,  to  facilitate  cleaning.  The  instruments 
selected  for  an  operation  should  be  cleaned  by  washing  with  green 
soap  and  warm  water,  a  nail-brush  being  used  on  the  locks  and 
serrated  parts,  such  as  the  jaws  of  artery  forceps.  The  blades  of 
the  knives  should  then  be  wrapped  in  cotton  to  prevent  their 
being  dulled,  and  the  needles  stuck  in  a  piece  of  gauze  to  keep 
them  from  being  lost,  and  the  instruments  wrapped  in  atov^el. 
The  bundle  should  be  tied  with  a  bandage,  or  fastened  with  safety 
pins,  and  disinfected  by  being  placed  in  a  sterilizer  and  oteamed 
for  forty  minutes.  After  the  administration  of  the  an£esi:hetic  has 
been  commenced,  the  package  should  be  opened,  and  the  instru- 
ments slid  into  trays  containing  sterilized  water. 

An  equally  effective  though  more  troublesome  plan  is  to  place 
the  instruments  in  a  1  per  cent,  solution  of  carbonate  of  soda,  and 
boil  for  ten  minutes.  The  soda  is  a  germicide  and  also  prevents 
rusting. 

In  minor  operations,  it  is  frequently  thought  sufficient  to  place 
the  instruments  in  a  tray  containing  a  5  per  cent,  solution  of  car- 
bolic acid  for  fifteen  minutes  and  then  pour  off  the  solution  and 
refill  the  tray  with  sterilized  vvater. 

If  an  instrument  is  dropped  on  the  floor  during  an  operation,  it 
should  not  be  used  until  disinfected  ag-ain. 


PRINCIPLES    OF    SURGERY.  219 

When  an  operation  is  over,  the  instruments  should  be  v^ell 
washed,  carefully  dried,  and  returned  to  their  cases. 

Sponges. — During  the  lirst  craze  for  asepsis,  sponges  were 
almost  abandonsd,  and  pledgets  of  cotton  or  wads  of  gauze  used 
in  their  place.  These  artificial  substitutes  proved  unsatisfactory, 
and  it  was  found  that  with  care  sponges  could  be  rendered  per- 
fectly sterile,  they  again  returned  to  favor.  Some  surgeons  even 
now  throw  a  sponge  away  after  using  it  in  one  case,  doubting  the 
power  of  germicides  to  destroy  the  microorganisms  with  which  it 
may  have  become  infected,  but  it  is  illogical  to  suppose  that  if 
the  sponge,  which  was  once  filled  with  decomposing  matter,  can 
ever  be  rendered  aseptic,  that  the  process  cannot  be  repeated. 
Sponges  can  be  used  and  resterilized  many  times  ^ith  safety,  the 
only  limit  being  the  resistance  of  their  tissue  to  the  action  of  the 
solutions  used.  IV hen  the  sponge  becomes  soft  and  friable  frnm 
the  effect  of  an  antiseptic  or  bleaching  fluid,  it  shoid  be  destroyed. 

If  sponges  could  be  boiled  then  sterilization  would  be  much 
simplified,  but  very  hot  water  causes  them  to  shrink,  to  lose  their 
elasticity,  and  to  become  darker  in  color;  hence,  they  should  never 
be  put  in  a  solution  warmer  than  can  be  comfortably  borne  by  the 
hand.  The  following  is  one  of  the  best  methods  to  sterilize  new 
sponges : 

1st.  Put  the  sponges  in  a  bag  and  beat  them  well  to  remove 
sand. 

2d.  Wash  them  several  times  with  warm  water  and  green  soap 
to  remove  dirt,  and  adulterants  sometimes  put  in  by  dealers  to 
render  them  more  saleable. 

3d.  Soak  them  for  twenty-four  hours  in  a  "A  per  cent,  solution 
of  hydrochloric  acid  to  dissolve  calcaeous  matter. 

4th.  Wash  them  in  plain  w^ater  until  the  acid  is  removed,  which 
can  be  determined  by  testing  with  blue  litmus  paper. 

5th.  Put  them  in  a  saturated  solution  of  permanganate  of  po- 
tassium, and  allow  them  to  remain  until  stained  a  mahoffanv 
brown.  Then  rinse  in  sterilized  \^  ater.  It  must  be  remembered 
that  the  strength  of  the  solution  deteriorates  after  a  number  of 
sponges  have  been  through  it,  and  that  fresh  permanganate  has 
to  be  added  from  time  to  time  to  keep  it  up  to  the  standard. 
When  this  is  done  the  sponges  should  be  taken  out  of  the  liquid. 


220  PRINCIPLES    OF    SURGERY. 

the  permanganate  dissolved,  and  the  spoQges  put  back,  for  if  the 
drug  is  put  in  on  the  sponges  it  discolors  them  in  spots. 

6th.  After  the  sponges  have  been  freed  from  an  excess  of  per- 
manganate they  should  be  placed  in  a  saturated  solution  of  oxalic 
acid  until  bleached.  Care  should  be  taken  to  remove  them  as 
soon  as  tbey  are  white,  as  a  prolonged  bath  in  the  bleaching  fluid 
softens  their  fibre.  Additions  of  oxalic  acid  have  to  be  made  to 
the  solution  at  inteivals  to  keep  it  up  co  the  standard. 

7th,  Put  them  in  a  1 :10U0  solution  of  bichloride  of  mercury  for 
one  hour. 

8th.  Finally  wash  them  in  repeated  baths  of  sterilized  water  to 
remove  all  trace  of  the  chemicals  previously  employed. 

It  is  almost  as  easy  to  prepare  several  hundred  sponges  as  it  is 
to  prepare  a  dozen,  and  in  hospitals  it  is  customary  to  sterilize  a 
large  number  at  one  time.  When  this  is  done,  and  the  process 
just  described  is  completed,  the  sponges  are  placed  in  large  glass- 
covered  jars  which  are  filled  with  a  3  per  cent,  aqueous  solution  of 
carbolic  acid,  to  ',^hich  a  small  proportion  of  glycerine  is  added 
to  prevent  the  spooges  from  becoming  blackened.  Before  each 
operation  the  required  number  of  sponges  are  removed  from  the 
solution  by  a  pair  of  aseptic  forceps,  and  washed  in  sterilized 
water  to  remove  the  carbolic  acid. 

After  sponges  are  used  in  an  operation  they  should  be  well 
washed  in  cold  water  to  free  them  from  blood,  dried,  and  put  into 
a  bag.  When  they  accumulate  in  sufficient  numbers  they  are 
again  sterilized. 

To  sterilize  sponges  which  have  been  used  they  should  be  soaked 
in  a  saturated  solution  of  baking  soda  for  twelve  hours  to  remove 
all  animal  matter,  rinsed  plain  water  to  remove  the  alkali,  and 
then  put  in  the  solution  of  permanganate  of  potassium  and  after- 
wards treated  by  the  method  just  described. 

Basins,  etc. — Irrigators,  pitchers,  basins  and  trays  used  in  the 
operating  room  should  be  scrupulously  clean.  They  should  be 
made  of  some  material  which  is  not  affected  by  solutions  of  cor- 
rosive sublimate,  such  as  glass,  rubber,  porcelain  or  agateware. 

Prior  to  the  operation  they  should  be  T\'ashed  with  water  and 
green  soap,  and  filled  with  a  1:1000  solution  of  bichloride  of  mer- 
cury. Before  using,  the  solution  should  be  poured  out  and  the 
utensils  washed  in  sterilized  water. 


PRINCIPLES    OF    SURGERV.  221 

OrERATiMG-RooM  LiNEN. — The  linen  which  requires  sterilization 
for  an  operation  consist  of  sheets,  pillow-cases,  tow^els  and  ope- 
rating gowns.  The}"  should  be  placed  in  the  sterilizer  and  sub- 
jected to  high  temperature  for  fory  minutes  before  the  operation, 
and  removed  as  needed  by  an  assistant  whose  hands  have  been 
rendered  sterile.  After  the  operation  they  should  be  soaked  in 
a  cold  solution  of  baking  soda  to  remove  the  blood,  immersed 
for  one  hour  in  a  1,000  solution  of  bichloride  of  mercury,  Trashed 
in  plain  water,  and  sect  to  the  laundry. 

Ligatures  axd  Sutures. — Ligatures  are  made  from  a  variety  of 
materials,  and  sterilized  by  many  different  processes.  The  fol- 
lowing are  methods  of  preparing  silk,  cat-gut,  and  silk-\^orm  gut: 

Silk. — In  hospitals  silk  is  usually  kept  in  a  glass  ligature  box, 
which  has  several  spools  for  the  different  sizes.  The  silk,  when 
it  comes  from  the  dealer,  is  wound  on  the  glass  spools,  and  the 
spools  containing  the  silk  boiled  in  water  for  five  minutes  and 
returned  to  their  places  in  the  box  The  ligature  box  is  then  filled 
M  ith  equal  parts  of  alcohol  and  water,  to  which  is  added  enough 
carbolic  acid  to  make  a  5  per  cent,  solution.  Three  days  before 
an  operation  the  hands  should  be  sterilized,  and  the  required 
quantity  of  the  different  sizes  of  silk  removed  frcm  the  ligature 
box,  and  washed  in  several  sterilized  waters  to  remove  the  carbolic 
acid.  It  should  then  be  m  ound  on  small  glass  spools,  which  are 
rendered  aseptic  by  washing  in  a  solution  of  bichloride,  and  the 
spools  placed  in  a  clean  test  tube,  the  end  of  which  is  tightly 
plugged  with  absorbent  cotton.  The  tube,  or  ignition  tube,  as  it 
is  called,  should  be  placed  in  the  sterilizer  for  half  an  hour  on 
three  successive  days  and  subjected  to  high  temperature.  The 
plug  of  cotton  should  not  be  removed  until  the  silK  is  actually  re- 
quired for  use- 

Cat-Gut. — Cat-gut  is  exceedingly  difficult  to  sterilize,  as  it  con- 
tains a  large  proportion  of  fat,  and  is  infected  with  germs  from 
its  very  source,  being  made  from  the  sub-mucosa  of  the  intestines 
of  sheep.  The  ready-prepared  article  found  on  the  market  is  not 
trustworthy^  and  should  not  be  used.  Raw  cat-gut  should  be 
soaked  in  ether  for  twenty-four  hours  to  remove  the  fat.  It 
should  then  be  sterilized  by  boiling  in  alcohol.  To  do  this  effec- 
tually, the  cat-gut  should  be  wound  on  a  glass  reel,  immersed  in  a 


222  PRINCIPLES    OF    SURGERY. 

bottle  filled  with  absolute  alcoliol,  and  the  mouth  of  the  bottle 
tightly  plugged  with  absorbent  cotton.  The  bottle  should  then 
be  placed  in  a  water- bath,  care  being  taken  that  evaporation 
doe»  not  leave  any  part  of  the  reel  uncovered. 

After  the  process  has  been  completed,  if  it  is  desired  to  chroma- 
cize  the  cat- gut,  and  thus  render  it  less  absorbable,  it  can  be  done 
by  placing  it  in  a  solution  of  one  part  chromic  acid,  200  parts  car- 
bolic acid,  and  4,000  parts  distilled  water,  for  fortj -eight  hours. 
Only  a  quantity  of  cat-gut  equal  in  weight  to  the  carbolic  acid  in 
the  solution  should  be  immersed,  as  a  larger  quantity  would  not 
be  thoroughly  chromacized,  and  a  small  quantity  might  be  over- 
prepared.  After  being  thus  sterilized,*  or  chromacized,  cat-gut 
should  be  kept  in  absolute  alcohol.  When  required  for  use,  the 
quantity  needed  should  be  removed  with  surgically-clean  hands, 
again  boiled  in  alcohol,  and  placed  in  a  tray  containing  a  mixture 
of  one  part  glycerine  and  nine  parts  alcohol,  which  gives  the  gut 
greater  smoothness  and  pliability. 

Silk-Worm  Gut. — -Silk-worm  gut  can  be  rendered  sterile  by 
boiling,  by  baking,  or  by  immersing  in  solutions  of  carbolic  acid, 
or  bichloride  of  mercury.  The  following  method  is  an  excellent 
one:  The  ragged  ends  of  the  strands  are  clipped,  and  the  bunch 
put  in  a  1  per  cent,  alcoholic  solution  of  methylin  blue,  where 
they  should  remain  for  twenty-four  hours.  This  stains  them  a 
dark  violet,  and  renders  them  more  easily  seen.  They  are  then 
rinsed  in  water  and  soaked  in  a  1:1000  bichloride  of  mercury 
solution  for  twenty- four  hours.  They  should  be  kept  in  absolute 
alcohol  until  needed. 

Drainage  Material. — Drainage  is  usually  effected  by  rubber 
tubing,  glass  tubes,  strips  of  gauze,  or  strands  of  cat-gut. 

Euhher  drainage  tubes  should  be  prepared  by  first  washing 
them  well  with  soap  and  water  and  rinsing  in  clear  water,  then 
soaking  for  twenty-four  hours  in  a  1:1000  solution  of  bichloride 
of  mercury,  and  finally  storing  them  in  a  glass  jar  containing  a 
5  per  cent,  solution  of  carbolic  acid.  Before  using,  the  disinfect- 
ants should  be  removed  by  rinsing  in  boiled  water. 

Glass  drainage  ttibes  should  be  washed  with  soap  and  water, 
boiled  for  half  an  hour  in  a  1  per  cent,  solution  of  carbonate  of 
soda,  and  kept  in  a  5  per  cent,  solution  of  carbolic  acid.  Rinse 
in  pure  water  before  using. 


PRINCIPLES    OF    SURGERY.  223 

Gauze  drains  are  strips  of  aseptic  gauze  one  yard  long  and  about 
au  inch  wide.  They  should  be  cut  by  the  draw- thread  method, 
thus  preventing  ravelling.  The  strips  are  made  in  little  rolls,  and 
placed  in  a  tube,  and  sterilized  in  the  manner  described  for  the 
sterilizatior  of  silk.  When  required  for  use,  the  plug  of  cotton 
should  be  removed,  and  the  strips  handed  to  the  surgeon  by  meaus 
of  sterilized  forceps. 

Dkessings— C'ozli^o/?.. — Eeliable  cotton  can  be  purchased  from 
dealers  put  up  in  cartoons.  It  may  be  v\iell,  however,  to  sterilize 
it  again  by  baking  in  a  hot-air  oven  for  an  hour  before  using. 

Game. — Gauze  can  be  purchased  on  the  market,  put  up  in  her- 
metically-sealed jars,  v^hich  is  perfectly  reliable.  Except  where 
very  large  quantities  are  used,  it  will  be  found  more  satisfactory, 
as  well  as  economical,  to  use  the  preparation  of  some  reliable 
manufacturer  than  to  attempt  its  preparation. 

The  following  are  methods  of  .making  the  varieties  of  gauze 
most  commonly  used : 

Plain  Aseptic  Gauze. — Soak  the  cheese-cloth  for  one  hour  in  a 
sud  of  soft  soap  and  water  to  remove  the  "sizing,'^ wash  several 
times  in  clear  water  to  free  it  from  soap,  and  then  steam  in  the 
sterilizer  for  an  hour,  and  store  in  clean  glass  jars  having  well- 
fitting  covers. 

Bichloride  Gauze. — Free  the  cloth  from  sizing  and  remove  all 
traces  of  the  soap,  as  in  the  previous  process,  and  immerse  it  for 
several  hours  in  a  1:1000  solution  of  bichloride  of  mercury,  to 
which  has  been  added  a  little  glycerine.  Then  dry  in  the  steri- 
lizer and  store  in  clean  jars. 

Carholized'  Gauze  is  prepared  in  the  same  manner  as  bichloride 
gauze,  except  that  a  5  per  cent,  solution  of  carbolic  acid  is  used 
in  place  of  the  bichloride  solution. 

Iodoform  Gauze  is  prepared  by  taking  plain  aseptic  gauze  and 
cutting  it  in  three-yard  lengths.  Each  length  is  placed  in  an 
emulsion  composed  of  ten  drachms  of  iodoform  and  six  ounces  of 
soapsuds —the  suds  being  formed  by  the  addition  of  castile  soap 
to  sterilized  water.  After  thoroughly  rubbing  the  emulsion  into 
the  meshes  of  the  gauze,  it  is  gently  squeezed,  sprinkled  lightly 
with  glycerine,  and  dried  in  a  hot-air  oven  at  a  low  temperature- 
It  should  then  be  stored  in  colored  glass  jars. 


224  PRINCIPLES    OF    SURGERY. 

Rubber  Tissue. — In  dressing  wounds  strips  or  sheets,  of  rub- 
ber tissue  will  frequently  be  used.  They  should  be  sterilized  by 
soaking  in  a  solution  of  1 :  1000  of  bichloride  of  mercury  for  an 
hour,  and  then  rinsed  in  boiled  water. 

Bandages. — Pressings  are  secured  in  place  by  bandages  of  cot- 
ton or  flannel.  They  should  be  rendered  aseptic  by  heating  in  the 
sterilizer  for  an  hour  before  using. 


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different  Instruments.  We  are  not  agents  for  an- 
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Surgical  Instrument  line. 

Write  to  Us  for  Quotations. 


Since  this  material  was  introduced  into  surgery  by  Lister,  a  vast  amount  of  labor 
and  thought  has  been  expended  in  attempts  to  properly  prepare  it  for  use.  The 
literature  of  this  subject  is  very  extensive.  The  methods  and  suggestions  em- 
brace every  possible  device  for  rendering  it  sterile,  and  recommend  a  vast  list  of 
antiseptics  for  its  preservation. 

Notwithstanding  all  this,  reports  have  heretofore  shown  that  none  of  the  infi- 
nite number  of  processes  were  wholly  satisfactory.  Those  processes  that  produced 
sterile  ligatures  made  them  brittle  ;  methods  that  did  not  make  the  strings  tender, 
left  them  infected.  Finally,  if  by  chance  made  aseptic,  they  were  easily  reinfected 
so  that  no  one  was  really  furnishing  absoluteh'  aseptic  ligatures. 

We  have  given  attention  to  this  vexing  problem  in  our  laboratories  almost  con- 
tinuously for  ten  years — trying  every  conceivable  plan — following  every  suggestion, 
working  out  every  method.  .  We  venture  to  say  that  our  experiments  and  re- 
searches have  cost  many  times  our  profits  upon  tnis  material.  The  difficulties  to 
be  overcome  can  be  partiallj'  realized  when  we  consider  the  nature  of  this  gut  (the 
intestines  of  sheep,  twisted  into  hard  cords) .  It  is  a  gelatenous  substance,  often 
infected  with  the  deadly  Anthrax,  and  sometimes  with  germs  even  more  resistant 
than  those  of  Anthrax.  It  is  impenetrable  by  most  solutions,  destroyed  by  heat, 
rotted  by  chemicals  ;  and,  worse  than  all,  a  substance  that  will  gather  germs  in 
handling.  It  is  a  jelly-like  thing,  that  in  itself  receives,  holds  and  nourishes  germ 
life  ;  easy  to  infect,  hard  to  disinfect. 

At  last  we  produced  the  Red  Cross  Aseptic  Ligatures,  that  are  as  their  name  in- 
,  dicates — aseptic — free  from  genu  life,  protected  from  infection  by  handling,  with 
their  tensile  strength  and  elasticity  unimpaired.  The  processes  by  which  this  is 
accomplished  have  been  published  in  detail.  Their  completeness  consists  in  the 
fact  that  sterilization  is  accomplished  by  means  of  a  series  of  operations  by  which 
the  organic  structure  of  the  infecting  bacteria  is  removed  and  their  life  destroj'ed 
without  touching  the  strings  by  the  hands.  In  brief,  the  Ligatures  are  sterilized 
while  inside  a  protecting  envelope  that  allows  the  sterilizing  agents  to  penetrate, 
but  prevents  the  operator  from  touching  the  gut.  The  Ligatures  reach  the  surgeon 
in  this  same  envelope  (still  further  protected  by  an  outer  covering),  then  sealed  in 
glass.  These  strings  reach  the  wound  (untouched  save  by  the  surgeon)  direct  from 
the  sterilizer. 

We  are  safe  in  saying  no  known  system  approaches  that  under  which  Red  Cross 
Ligatures  are  sterilized  and  handled.  Our  claims  for  them  have  been  verified  by 
purposely  infecting  strings  with  the  most  resistant  germs  and  passing  them  through 
the  sterilizing  processes.  Thorough  bacteroilogical  tests  have  shown  that  the 
germs  were  wholly  destroyed. 

Further  ample  proofs  have  been  given  by  exhaustive  tests  made  by  our  surgical 
friends  during  the  course  of  experiments,  and  by  the  fact  that  in  the  thousands  of 
packages  sent  out  since  placing  them  upon  the  market,  not  one  report  has  been 
made  of  the  occurrence  of  infection  from  Red  Cross  Aseptic  Ligatures.  These 
Ligatures  are  put  up  in  strings  30  inches  long,  each  string  in  a  double  germ-proof 
envelope  ;  12  envelopes  are  put  in  a  glass  bottle  and  sealed.  They  therefore  can- 
not become  infected  in  their  handling  and  sale  by  the  dealer.  One  or  more  liga- 
tures can  be  renioved  without  endangering  the  remaining  strings.  If  the  inner  en. 
velope  is  opened  with  disinfected  hands  or  forceps  all  possible  danger  is  easily 
avoided.  The  important  point  is  that  they  are  rendered  absolutely  sterile  in  their 
treatment,  and  with  a  moderate  amount  of  care  will  reach  the  surgeon  in  perfect 
condition.     A  sample  of  these  Ligatures  will  be  sent  any  surgeon  on  application. 

JOHNSON  &  JOHNSON,  New  Brunswick,  N.J, 


Surgical  Instruments. 

Fever  Thermometers,  Hypodermic  Syringes, 
Operating  Cushions,  Obstetrical  Cases  and 
Forceps;  Dissecting,  Pocket,  Buggy  and  8ad- 
dle  Cases.  All  of  first  quality,  latest  im- 
provements, AND  AT  NEW  YORK  PEICES. 
We  solicit  examination  and  comparison  be- 
fore purchasing. 

ROBINS, 

Marsha//  and  Second  Streets,  /i/C//MOND,  VA. 


BLOOD    GENESIS 


T 


HE  formation  of  a  rich  nutrient  circulating  fluid.     Blood  which  shall  contain  an  abundance 

of  red  corpuscles  of  the  necessary  structural  and  physico-chemical  integrity. 
How  to  "  build  "  such  blood  is  an  ever-present  therapeutic  problem  for  the  physician  to  solve. 

i1\ 


is  a  powerful  blood-forming  agent ;  it  induces  the  generation  of  haemoglobin,  the  oxygen  carrying' 

constituent  of  the  blood  ;  it  is  a  genuine  haemoglobinogenetic.     It  feeds  the  red  corpuscles 

with  organic  Iron  and  Manganese  which  are  quickly  and  completely  absorbed  in  cases  of 

Anaemia  from  any  cause.  Ghlorosls,  Amenorrhoea,  Chorea,  Bright's  Disease,  etc. 

To  assure  proper  filling  of  prescriptions,  order  Pepto-Mangan  "Gude"  in  original  bottles  ( 3  xi). 

IT'S    NEVER    SOLD    IN    BULK. 

I  M.J.    BREITENBACH    COMPANY,    SoIe  Agents  for  U.  S.  and  Canada, 

56  &  58    WARRENJST.,    NEW   YORK. 


LABORATORY. 

LEIPZIG,    GERMANY. 


Yale  Surgbon's  Chair. 


'99 


^^HIGHEST  AWARD  WORLl^^'S 


!,  OCT.  4th,  1893. 


^1      r^ 


'Fig.  V. — Semi- Reclining. 


w 

(^.\     \  Qth.    The  leg^  and  foot  rests  folded  out  of  the  operator's  way 
.^  at  any  time— Fig-s.  XI,  XV  and  XVIL 

10th.    Head  Rest  universal  ia   aujustment,  with  a  raug-e  of 
irom  14  inches  above  seat  io   13  inches  above  back  of 
chair,  furnishing- a  perfect  nrportia  Dorsal  or  Sim'« 
„  position. — Fig-s.  XIII  and  XV. 

llths    Affording- unlimited  modifications  of  positions. 
12tfa.    Stability  and  firmness -while  being- raised  and  rotated* 
13th.    0;:ly  successful  Dorsal  position  ■withntU  moi'ing patient. 
14t!a-    Croad  turntable  upon  which  to  rotate  the  chair,  -whicll 

cannot  be  bent  or  twisted. 
ISth.    Sirtrdsupon  its  owa  merits  and  not  tipon  the  repwta- 
tiou  of  others. 


1st.  Raised  by  foot  and  lowered  by  automatic  device. — Fig-.  I. 

2d.  Raising-  and  lowering-  without  revolving-  the  upper  part 
of  the  chair. — Fig-  VII. 

3d.    Obtaining  heig-ht  of  39J^  inches.— Fig-.  VII. 

4th.  As  strong  in  the  highest,  as  when  in  the  lowest  position. 
—Fig.  VII. 

5th.  Raised,  lowered,  tilted  or  rotated  -withoat  disturbing-  pa. 
tient. 

6th.  Heavy  steel  spring's  to  balance  the  chair. 

7th.  Arm  Rests  not  dependent  on  the  back  for  support.— Figi 
VII — always  ready  for  use;  pushed  back  when  using-  stir- 
rups— Fig.  XVII — may  be  placed  at  and  away  from  side 
of  chair,  forming-  a  side  table  for  Sim's  position— Fig-. 
XIIL 

Sth.  Quickect  and  easiest  operated  and  most  substantially  se- 
cured  in  positions. 


Fig.  XVIT— Dorsal  Position, 


Pronounced  tli3  ne  puis  ultra  by  the  Surgeon,  Gynsecolegist,  Ocnlist  and  Aurlst. 

MANUFACTURKD    SXCLUOtVEUY    BY 

Canton    Soe^^sscAL   hn^    Dental   Chair   Co 

38  t«  64  East  Eighth  and  60  to  62  South  Walnut  Streets,  CANTON.  OHIO. 


MEDICAL  BOOKS. 
BlaoK  Book^s,  Note  Bool<;s, 

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629  East  Broad  Street,  RICH3IOXD,  VA. 


e:©t^bil.isiie:d  is36. 


MAKERS  OF 

Surgical  Instruments,  Hospital  Supplies,  Aseptic 
Iron  and  Glass  Furniture,  &c. 


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